gastrointestinal bleeding Flashcards
Gastrointestinal bleeding with tachycardia and hypotension - next step
Bolus of normal saline (or ringer)
the etiology of he bleeding is no as important as fluids
Gastrointestinal bleeding - NS vs D5W
D5W does not stay in the vascular space to raise BP as well as N/S
MCC of upper GI bleeding
ulcer disease
causes of upper GI bleeding
- ulcer 2. gastritis 3. esophagitis 5. duodenitis
6. cancer 7. varices
MCC of lower GI bleeding
diverticulitis
causes of lower GI bleeding
- diverticulitis 2. angiodysplasia (AV malformations)
- polys or cancer 4. IBD 5. hemorrhoids
- upper GI with rapid transit from high volume
the most important initial management for GI bleeding
assesing BP
orthostasis is defined as
more than a 10 point rise in pulse when going from lying down to sitting or standing up or systolic pressure drop of 20 points when sitting up
severity of blood loss based on physical findings
15-20% of blood loss –> orthostasis
30% –> pusle more than 100
30% –> systolic BP less than 100
the only form of GI bleeding in which physical examination helps determine etiology …. / signs
variceal bleeding
variceal bleeding - physical findings
- signs of liver disease
- spider angiomata and caput medusa
- splenomegaly
- palmar erythema
- asterixis
Initial management of GI bleeding based on
the severity
NOT THE CAUSE
GI bleeding - initial diagnostic test? (most important)
is far more important to replace fluids and check Hematocrit, platelet count and coagulation tests (PT INR) than to do an endoscopy
red blood in rectum after upper GI bleeding
10% of those with red blood from rectum have high volume upper GI bleeding with rapid transit time
GI bleeding - Nasogastric tube
VERY LIMITED BENEFIT –> no therpay delivered through it BUT –> it can rapidly identify upper GI bleeding and hence, who needs ensocopy for banding before colonoscopy
GI bleeding - Nasogastric tube sensitivity
70%
if you see bile –> fully sensitive
GI bleeding - Nagogastric tube - upper endoscopy
if upper endoscopy will be done anyway –> limited role for NG tube
black stool in person with cirrhosis but there is not hematemesis - NG?
an NG showing red blood can tell you to use octreotide for varices and arrange urgent endoscopy for possible banding of varices
GI bleeding - fluid resuscitation importance
80% of GI bleeding will stop spontaneously if the fluid resuscitation is adequate
Most patients die of inadequate fluid replacement
GI bleeding - additional tests (only names)
- nuclear bleeding scan
- angiography
- capsule endoscopy
- CT or MRI ob abdomen
- EKG, lactate level
GI bleeding - indication for nuclear bleeding scan
endoscopy unrevealing in a massive acute hemorrhage
LACKS OF ACCURACY
GI bleeding - indication for andiography
specific vessel or site of bleeding needs to be identified prior to surgery or embolization of the vessel –> used only in massive non-responsive bleeding
GI bleeding - indication for capsule endoscopy
small bowel bleeding –> if upper and lower endoscopy do not show etiology
GI bleeding - indication for CT or MRI of abdomen
Not useful in GI bleeding
GI bleeding - indication for EKG, lactate
in severe bleeding –> ischemia
GI bleeding treatment (only names)
- fluid replacement
- Packed red blood cells (if indicated)
- Fresh frozen plasma (if indicated)
- platelts (if indicated)
- octreotide if indicated
- endoscopy to determine the diagnosis and administer some treatment
- IV PPI for upper GI bleeding
- surgery (if indicated)
GI bleeding treatment - fluid replacement
high volumes (1-2 L an hout) of saline or Ringer lactte in those with acute severe bleeding
GI bleeding treatment - Packed red blood cells
if HcT is below 30 in those who are older or sufer from CAD
if the patients young, transfusion may not be needed until Hct is very low (under20-25)
GI bleeding treatment - Fresh frozen plasma
if PT or INR is elevated and active bleeding is occuring
GI bleeding treatment - Platelets
if the count is below 50.000 and there is bleeding
GI bleeding treatment - Octreotide
for variceal bleeding
GI bleeding treatment - endoscopy
to determine the diagnosis and administer some treatment (band varices, cauterise ulcer, infect epinephrine into bleeding gastric vessels)
GI bleeding treatment - PPI
IV for Upper GI bleeding
GI bleeding treatment - surgery
to remove the site of bleeding if fluids, blood platelets, and plasma will not control the bleeding
Administration of platelets to PREVENT bleeding
only if below than 10-20.000
GI bleeding - treatment from esophageal and gastric VARICES in addition to Fluids, blood, platelets, plasma (only names)
- octreotide (somatostatin)
- Badning
- TIPS
- propranolol or nadolol
- antibiotics
GI bleeding from varices - octreotide
(somatostatin) –> to decrease portal pressure
GI bleeding from varices - banding
endoscopy obliterates esophageal varices
TIPS?
tranjugular intrahepatic portosystemic shunting
GI bleeding from varices - TIPS
used to decrease portal pressure in those who are not controlled
GI bleeding from varices - propranolol or nadolol
to prevent subsequent epispodes of bleeding
they will not to anything for the current episode of bleeding
GI bleeding from varices - antibiotics
to prevent SBP with ascites
GI bleeding from varices - sclerotherapy
it is never the right answer if banding is techincally possible
