Gastrointestinal bleeding Flashcards
what is melena caused by
oxidation of Hb as it passes lower GI tract
Bleeding that originates proximal to ligament of treitz is
Upper GI bleed
Melena or hematemesis or brisk bleeding - hematochezia can suggest
upper GI bleed
Organs proximal to ligament of treitz
esophagus
stomach
duodenum
Organs distal to ligament of treitz
jejunum
ileum
colon
Hematochezia or melena (from small bowel or right colon if slow) suggests
Lower GI bleed
MOST common causes of Upper GI bleed
1) PUD
2) Varices
3) Esophagitis
4) MW tear
If bleeding is non-variceal how long will it last
80% will stop on their own
3 features make you worries about MASSIVE bleed
1) unstable hemodynamically
2) presents with hematochezia or frank hematemesis
3) blood transfusion needs
3 features make you worries about WORSE outcome
1) > 60
2) concurrent illness
3) Onset WHILE hospitilized
4) coagulopathy
First thing to do when managing an UGIB
1) resuscitate!
Second thing to do when managing an UGIB
PPIs - give IV Bolus-infusion
Octreotide - only for variceal bleed
For all UGIBs what medical therapy is given
PPIs - octreotide for variceal
Third point in management of UGIB
Correct coagulopathy
Fourth thing done in management of UGIB
Endoscopy to localize/treat bleed
Resuscitation in UGIB
1) Airway
2) 2 LARGE bore peripheral IVs
3) Normal saline IV
4) packed RBC transfusion
PPIs act on which cell in the stomach
Parietal cell, block acid production
What does the higher pH promote?
Clot stability
3 roles for endoscopy
1) diagnose
2) prognosis risk/stratify lesion
3) treat lesion - therapy
2 low risk lesions
clean base/flat spot - NO ENDOSCOPic therapy
Example of an intermediate lesion
Adherent clot - - consider therapy
2 examples of HIGH risk lesions
Nonbleeding, but visible vessels
or active bleeding - MUST TREAT
Medications used in endoscopy
- diluted Epi, Hemospray
If you can’t stop the bleeding endoscopically
Angiography with embolization needed/surgery
2 things happen when pressure goes up in portal system
1) Increased portal vascular resistance
2) Vasodilation and splanchnic blood flow
What should the difference between portal and systemic pressures be to get varices
12 mmHg at least
Clinical risk factor for variceal bleeding is
severity of liver disease
Endoscopic predictors of variceal bleeding
- size
- recent hemorrhage (wale marking, cherry spots)
2 differences in treatment/management of varieal vs non-variceal blood
- Give octreotide
- Give prophylactic antibiotics
endoscopically what is different from PUD vs variceal bleed
Band ligation used more than sclerotherapy
If band ligation fails can use
TIPS
what is the mechanism of action of octreotide in reducing portal hypertension
- vasoconstricts spanchnic vasculature
- given bolus-infusion
what does a TIPS do?
shunts blood from portal vein to hepatic vein
what are the risks of TIPs
encephalopathy, occlusion
Difference between variceal and gastric varice?
- use gluing rather than banding
when do you suspect that someone has an upper GI bleed presenting with hematochezia
- when hemodynamically unstable
- cirrhotic/NSAID/ Hx of PUD
What are the causes of painless acute lower GIB
- Diverticulosis
- Hemorrhoids
- angiodysplasia
- colon cancer/polyp
- Meckel’s
Cause of a painful LGIB
anal fissure
Causes of bloody diarrhea
- infectious colitis
- ischemic colitis
- IBD
4 causes of Acute Lower GIB
- diverticulosis
- angiodysplasia
- ischemic colitis and hemorrhoids
- neoplasia/other colitis
Difference between UGIB and LGIB in terms of management
- LGIB - do a colonoscopy to treat and localize lesion
if a patient cannot undergo colonoscopy what to do?
send for angiography -
RBC scan first to screen for active bleed
2 scans before you send patients to angiography
CT angio
or
RBC scan
