GI Bleed Flashcards
what is the most common location of an aortic-enteric fistula?
3rd part of the duodenum
do mild elevations in INR (1.3 to 2.5) increase the risk of re-bleeding after endoscopy?
No
in what two scenarios should bleeding patients be intubated?
- Hematemesis
2, AMS
What is the classification system used to classify peptic ulcers?
Forrest classifcations system
How does a Forest class 3 ulcer appear and what endoscopic therapy is needed?
Clean based ulcer and no endoscopic intervention needed, just PPI
How does a Forest class 2c ulcer appear and what endoscopic therapy is needed?
Flat pigmented spot, no endoscopic intervention needed, just PPI
In terms of ACTIVE bleeding, recent bleeding or no bleed, what is the difference between forest class 1, 2, and 3
- active bleed
- recent bleed
- no bleed
what is the difference between forest class 1a and 1b ulcers and their treatment?
- 1a is an active and spurting lesions, treat with dual therapy (epi injection + thermal or clips) and IV PPI
- 1b is active but oozing
What is the different between forest class 2 and 2b ulcers and treatment?
- 2a is visible vessel treat with dual therapy (epi injection + thermal or clips) and IV PPI
- 2b is adherent clot treat with dual therapy (epi injection + thermal or clips) and IV PPI
How long do you treat with IV PPI forest class 1 and 2 ulcers
72 hours
what are the 5 techniques used to achieve hemostasis on bleeding lesions?
- Thermocoagulation
- Endoclips
- Epi injection
4.Hemospray - Over the scope clips
when to restart Aspirin after achieving hemostasis in a bleeding ulcer patient with CVD history?
when ulcer hemostasis is achieved
in pts with peptic ulcer bleeds, when does rebleeding occur most often>
within 72 hrs
in patients with severe ulcer bleed, that cant be fixed with endo, what are the two salvage therapies>
- Surgery
- radiographic embolization
which type of ulcer results in the setting of multi-organ failure?
gastric stress ulcer
what is the cause of gastric stress ulcers?
gastric mucosal hypoperfusion
in pts with gastric stress ulcers, what is seen on endoscopy
multiple shallow erosions in the proximal stomach
what can be given for gastric stress ulcer prophylaxis
IV H2 blockers or IV PPI
whats the time frame for EGD in pts with cirrhosis and bleeding
12 hours EGD
in cirrhotic patients, hepatic venous gradients greater than what number are associated with higher risk of rebleeed and treatment failure?
HVPG greater than 20
in variceal bleed patients who fail endoscopic therapy what is there last resort for treatment?
TIPS
whaT is the main complication of TIPS
ENCEPHALOPATHY
For isolated gastric varices in the fundus, what is the treatment?
splenectomy
in which gastric varices can you attempt EVL? which ones cant you attempt it?
EVL can be attempted in EGV1. If the fundus is involved at all, have to do TIPS
EGD should be performed in all patients with decompensated cirrhosis to screen for varices. However, In patients with clinically compensated cirrhosis, what patients should receive an EGD for variceal screening?
1.
2.
3.
4.
In DEcompensated cirrhosis pts, who should get EGD?
EGD should be performed in all patients with decompensated cirrhosis to screen for varices.
In patients with clinically compensated cirrhosis, what two clinical values can be used to predict the need for EGD?
- Transient elastography (liver stiffness (KPA>20
- Platelet count (less than 150)
if a patient with compensated cirrhosis has a platelet count above 150 and a liver stiffness kpa less than 20, if you defer EGD, what you should be done next to stratify risk of varices?
Defer EGD and repeat transient elastography in 1 year
What pressure gradient and/or liver stiffness measurement are considered CLINICALLY SIGNIFICANT PORTAL hypertension?
- Hepatic venous pressure gradient > 10mm hg
- Liver stiffness measurement >25kpa
In patients with CLINICALLY SIGNIFICANT PORTAL hypertension, what treatment is recommended?
NSBB (coreg preferred), If started EGD can deferred
In performing an EGD to screen for varices, if NO varices are seen on EGD, when should the next EGD screening be for patients in which the liver insult has resolved? vs the liver insult is ongoing (untreated hep c, alcohol)?
If insult resolved, EGD q3 years, and if ongoing insult, EGD q2 years
In performing an EGD to screen for varices, if SMALL varices are seen on EGD, what should be done next for patients with HIGH RISK FEATURES on EGD (red wales sign, advanced cirrhosis)? What should be done for patients with no high risk features?
- If high risk features, start a NSBB
- If low risk or no risk features, repeat EGD in 1 year for those with ongoing liver injury and 2 years for those without ongoing liver injury
In performing an EGD to screen for varices, if MEDIUM to LARGE NON BLEEDING varices are seen on EGD, what should be done next?
Start a NSBB or EVL for primary prophylaxis
Is there any benefit to doing a NSBB and EVL in patients with varices who have never bled for PRIMARY PROHPLAXIS?
No. Studies dont support
if cirrhotic patients with varices on EGD are started on NSBB, do they still need follow up EGD?
No, just titrate to a HR fo 55-60
In cirrhotic pts with varices, and can not tolerate NSBB, who can be done next?
EVL
In cirrhotic pts with varices who get banded, how often should banding be performed?
repeat every 2 to 4 weeks untul varices gione, then 6 monthsn then 1 year
How do NSBB decrease portal pressure?
decreased cardiac output (b1 blocked) and causes splanchnic vasoconstriction
Can cirrhotic patients with refractory ascites receive NSBB?
Yes but avoid high doses. if they get hepatorenal syndrome stop the medsa
can you use TIPS as a means of primary prophylaxis in patients with cirrhosis and non bleeding varices
No, not for primary prophylaxis
for cirrhotic patients with varices, when is it ideal to use both NSBB and EVL?
after an acute bleed. if they never bleed do one or the other
In cirrhotic patients with varices who get a tips, do they need EGD or EVL ny more?
No need for EVL or NSBB if they get a TIPS
In patients with obscure bleed, when should you do a anterograde deep enteroscopy (upper) vs retrograde (colon)?
If a capsule showed bleeding in the proximal 2/3 small bowel do upper/anterograde. If in the lower 1/2. do retro/lower.
How is diarrhea defined?
Decrease in the consistency of stool or increase in the frequency of stool >3/day more than 4 weeks
What are the 4 main categories of diarrhea ?
1 Inflammatory diarrhea
2 Watery diarrhea
3 Fatty diarrhea (steatorrhea)
4 Medication-induced diarrhea:
