Gastroenterology - GI Bleed Flashcards
Discuss the definition and differential for an Upper GI Bleed
- bleed anywhere from mouth to ligament of Treitz Differential - Peptic ulcer - Esophageal varices - Mallory Weiss tear - arterial venous malformation - tumour
Discuss the presentation and investigation for an Upper GI Bleed
Presentation - hematemesis (bright red or coffee ground emesis) - melena - increased bowel movements - hematochezia - anemia (dyspnea, pre-syncope, orthostatic dizziness, CP) - abdominal pain - DRE Investigation - Blood type and crossmatch - CBC, electrolytes, BUN, creatinine, AST, ALT, GGT, ALP, albumin, bilirubin, INR - BUNx10:Creatinine ratio >1.5
Discuss an approach to Upper GI Bleed
ABC
- two large bore IV
- foley catheter
- NG tube
Transfusion
- indication for pRBC
- hemastatic instability despite fluid rescusitation
- moderate anemia in high risk patients (elderly, CAD), <90
- severe anemia (<70)
- platelets or FFP if indicated
Empiric Treatment
- IV PPI to stabilize ulcer and promote clotting
- Esomeprazole 50mg IV or Panteprazole 40mg IV
- IV Somatostatin (Octreotide) for variceal as it constricts splanchic arteries decreasing portal hypertension
- Octreotide 50mcg bolus or 50mch/hr infusion
- Prophylactic antibiotic for cirrhosis
- Ciprofloxacin 400-1000mg IV for 7 days
- Ceftriaxone 1g IV daily for 7 days
- Prokinetic (metoclopramide or erythromycin) for EGD
Discuss the indications for EGD with Upper GI bleed
Urgent EGD if any of the following - Hemodynamically unstable - Hematochezia - Suspected varices - serious comorbidity Lower GI Bleed - wait for bleeding to stop and then do colonoscopy
Discuss preventative treatments for peptic ulcer disease
H-Pylori Therapy - Clarithromycin 500mg PO BID for 10-14d - Amoxicillin 1g PO BID (or flagyl if allergy) - PPI Proton Pump Therapy - Lansoprazole 30mg PO BID - Pantoprazole 40mg PO BID
Discuss preventative treatments for varices
Treat Varices
- Esophageal varices: injection with sclerosants
- Gastric varices: injfection with glue (cyanoacrylate)
- successful then beta blocker to decrease risk of re-bleed
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- for recurrent variceal bleed
- catheter is introduced through jugular vein into hepatic vein where a permanent stent is placed connecting main branch of portal vein to hepatic vein
- can worsen hepatic encephalopathy
Treat Underlying Cause
- liver transplant
List the Rome criteria for dyspepsia
Dyspepsia is defined as one or more of:
- bothersome postprandial fullness
- bothersome early satiation
- epigastric pain or burning
List the red flags for dyspepsia
- Age >55 with new onset
- Family history of upper GI Cancer
- Progressive dysphagia
- Odynophagia
- Unexplained iron deficiency
- persistent vomiting
- Palpable mass or lymphadenopathy
- Jaundice
- Unintentional weight loss
Discuss the treatment algorithm for dyspepsia with NSAID or GERD
Over 55 or red flags
- EGD
Less than 55 and no red flags
- test for H pylori
- negative treat with PPI for 8 weeks
- positive treat for H pylori
- fail then treat with PPI for 8 weeks
Fail Management
- Consider EGD
- abnormal then take biopsies and treat off finding
- normal then rapid urease test and/or histology for H pylori and if detected treat
Discuss the investigations and treatment for H Pylori
Investigation
- Non-invasive: urea breath test, stool antigen assay, serology for IgG
- Invasive: Biopsy urease testing or histology
Treatment
- Triple therapy for 7-14 days
- PPI BID
- Amoxicillin 1g BID
- Clarithromycin 500mg BID
- Quadruple therapy for 10-14 days
- PPI BID
- Bismuth 525mg QID
- Tetracycline 500mg QID
- Metronidazole 250mg QIDCompare the differences between erosive esophagitis and nonerosive reflux disease
Erosive
- endoscopically visible breaks in distal esophageal mucosa with or without troublesome symptoms of GERD
Nonerosive
- endoscopic negative with presence of troublesome symptoms
Discuss the typical, extraesophageal, and alarm features of GERD
Typical - Heartburn - Acid regurgitation Extraesophageal - Bronchospasm - Laryngitis - Chronic cough - Water brash (10mL of saliva per minute) - globus secretion - Odynophagia - Nausea Alarm - Vomiting - GI blood loss - Anemia - Weight loss - Dysphagia - chest pain
Discuss when to perform a upper endoscopic evaluation for GERD
- Atypical or alarm features
- Detect Barrett’s esophagus
- Dysphagia that was not resolved within 2-4 weeks of adequate BID PPI therapy
- Determine severity of esophagitis
Discuss the therapy for mild GERD (symptoms less than 2x/week and no erosion)
- follow up every 2-4 weeks
Lifestyle Changes - Weight loss
- Head elevation at night
- Avoidance of trigger foods
- Avoid alcohol, tobacco, caffeine
- Encourage salivation through gum
Symptoms Persist - start low dose histamine 2 receptor antagonist PRN -> increase dose and begin BID for 2 weeks
- continue to persist then discontinue and begin PPI (lansoprazole 30mg) PO OD
- if symptoms controlled therapy lasts for 8 weeks
Discuss the treatment for severe GERD (two or more episodes, impact quality of life, or erosive)
- PPI OD for 4-8 weeks in addition to lifestyle and dietary changes
- if symtpoms decrease then switch to low dose PPI and then H2RA
- goal to discontinue therapy in all patients except in those with Barrett’s
Discuss the screening guidelines for colon cancer
Average risk
- 50-74 with no family history or personal history get FOBT/FIT every 2 years or flexible sigmoidoscopy every 10 years
- abnormal FOBT require follow up with colonoscopy n 8 weeks
- if symptomatic then no role for FOBT
First degree family member Colon Cancer before 60
- Colonoscopy every 5 years beginning at 40 or 10 years before youngest diagnosis of polyp in family
Family History of HNPCC
- colonoscopy every 1-2 years at age 20 or 10 years younger than earliest case
Familial Adenomatous Polyposis
- sigmoidoscopy annually at age 10-12
Long Standing Chron’s or Ulcerative Colitis
- pancolitis begin screening at 8 years after onset of disease and then screen every 3 years in second decade and every 2 years in third decade and annually in fourth decade
- left sided begin 15 years after onset
Discuss the pathophysiology, risk factors and management of Barrett’s Esophagus
Pathophysiology
- Development of intestinal epithelium within the esophagus, seen on biopsy
- with dysplasia have increased risk of malignant transformation
Risk Factors
- Male
- Age >50
- Obese
- White
- Tobacco
- Long history of symptoms
Management
- High dose PPI indefinitely
- Surveillance gastroscopy every 3yrs if no dysplasia
- High grade dysplasia then endoscopic ablation with mucosal resection
- low grade have surveillance ever 6mon-1yr
Discuss the Forrest Prognostic Classification for Bleeding Peptic Ulcers
I (55-100%): Arterial bleeding IIa (43%) visible vessel IIb (22%) Sentinal clot IIC (10%) HEmatin covered flat spot III (5%) no stigmata of hemorrhage
Discuss the features and differential for lower GI bleed
Presentation - Hematochezia - Anemia - Occult blood in stool - Rarely melena Differential - Diverticulosis - Vascular (angiodysplasia, anorectal) - Neoplasm - Inflammation (IBD, radiation, infectious, ischemia) - Post-polypectomy
