GI BLEED Flashcards
what is the definition of a GI bleed?
bleeding of any degree from anywhere along the GI tract that indicates underlying pathology
what are the 2 divisions of GI bleeds?
- upper
- lower
what is an upper GI bleed?
hemorrhage proximal to the ligament of Treitz
70% OF BLEEDS
what is a lower GI bleed?
hemorrhage distal to the ligament of Treitz
30% of bleeds
what are the GI bleeds classified into?
- acute (<3 days) or chronic (>3days) bleeding
- overt or occult bleeding
-overt: visible bleeding
-occult: only detectable by chemical testing of a
stool specimen
what are the 8 risk factors of GI bleeds?
- hx of GI bleed
- H. Pylori
- NSAIDs
- anticoag use
- alcohol use
- cirrhosis
- vascular disease
- older age
what is PGE2?
it provides gastroprotection by increasing mucus secretion and inhibiting gastric acid secretion
what inhibits the production of prostagandins (PGs) through the inhibition of COX-1 and COX-2?
NSAIDs
basically they knock out PGE2
what is the #1 cause of an upper GI bleed?
peptic ulcer disease (PUD)
- gastric ulcer
- duodenal ulcer
what is the #1 cause of a lower GI bleed?
diverticular disease
- diverticulosis
- diverticulitis
what are the other causes of an upper GI bleed?
- erosive -gastritis, esophagitis
- esophageal or gastric varices
- esophageal cancer
- mallory weiss tears
- boerhaaves
what are the other causes of a lower GI bleed?
- hemorrhoids
- infectious colitis
- anal fissures
- IBD
-crohn’s, ucerative colitis - colorectal cancer
- iatrogenic- after biopsy or radiation
what are the s/s of a GI bleed in patients with occult bleeding?
asymptomatic
what are the s/s of anemia related to a GI bleed?
- fatigue/weakness
- dyspnea
- pallor
- lightheaded
what are the s/s of a GI bleed that is not occult or anemia related?
- heartburn
- abdominal pain
- weight loss…. should make you think malignancy
- hematemesis
- hematochezia
- melena
what does hematemesis indicate?
upper GI bleed
what is hematemesis?
vomiting of red blood or “coffee ground” material
what is coffee ground emesis and what is its patho?
vomit that is dark brown resembling coffee
- d/t conversion of red Hgb in brown hematin by
gastric acid
what does hematochezia indicate?
lower GI bleed (more often) or vigorous upper GI bleed w/ rapid transit through intestines
what is hematochezia?
passage of gross blood from rectum
bright red blood
what does melena indicate?
upper GI bleed usually, but can occur w/ small intestine or proximal colonic bleed
what is melena?
black tarry stool
what can black stool that does not contain occult blood be d/t?
ingestion of iron, bismuth (pepto bismal), or various foods
what is the definition of hemodynamic instabililty?
occurs when there is a decrease in BP leading to lowered blood flow to the body’s organs
what are primary hemodynamic parameters?
HR, and BP
what are advanced hemodynamic parameters?
SV, CO, TPR
what is characterized as mild hypovolemia?
<15% blood vol loss w/ resting tachycardia
what is characterized as moderate hypovolemia?
15-40% blood vol loss w/ orthostatic hypotension
what is characterized as severe hypovolemia?
> 40% blood vol. loss w/ hypotension
what are indicators of shock or hypovolemia?
tachycardia, tachypnea, pallor, diaphoresis, confusion, oliguria
why would a patient with a GI bleed present with oliguria?
d/t less perfusion to the kidneys to be filtered
what are some external stigmata of bleeding disorders that can be seen in patients with GI bleeds?
petechiae or ecchymosis
what are signs of chronic liver disease that can be seen in a patient with a GI bleed?
spider angiomas, ascites, palmar erythema, dilated abdominal wall veins, splenomegaly
what are you looking for on digital rectal exam?
stool color, masses or fissures, stool specimen for occult blood
do you want vital signs including orthostatic measurements when doing PE for GI bleed?
duh
what are some meds that can increase risk of bleeding?
NSAIDs, aspirin, clopidogrel, anticoags, SSRI’s
what is hematemesis in regards to distinguishing it from hemoptysis?
blood passed w/ initial vomiting or after an initial (or several) non-blood bouts of emesis
in what percent of patients will Hx and PE suggest a dx in?
> 50%
is confirmatory testing required?
yes.
what labs do you get for GI bleed?
- CBC w/ diff
- type and cross-match *
- coagulation profile
- FOBT
- liver tests (AST, ALT, bilirubin, alk phos, albumin)
- BMP
- iron and ferritin
what can you sometimes do in a patient with a suspected upper GI bleed?
Nasogastric aspiration and lavage
what is the GOLD STANDARD test for an upper GI bleed?
upper endoscopy/EGD
what is the purpose of a upper endoscopy/EGD?
- examination of esophagus, stomach, and duodenum
- diagnostic and therapeutic
what can a flexible sigmoidoscopy and anoscopy be used for?
typical sx hemorrhoidal bleeding
what is the GOLD STANDARD test for a lower GI bleed?
colonoscopy
whats the purpose of a colonoscopy?
often done electively after routine preparation
significant bleeding- rapid prep delivered via NG tube for patients with hematochezia
when is a CT angiography done?
- bleeding rate of at least 0.5-1 mL/min is required for detection
- reserved for patients who cannot undergo endoscopy d/t hemodynamic instability
what is the first 2 steps of treatment for GI bleed?
secure airway- intubation may be required
2 large-gauge peripheral IV’s and/or central line
- IV fluid rescuscitation
- blood transfusion (Hgb <7)
>packed RBCs, platelets, FFP
are GI bleed management patients NPO?
yes
- you’ll also consult GI and/or gen surgery
what are the 3 pharamacotherapy options for GI bleed tx?
- IV PPI for all upper GI bleed
- octreotide for variceal bleeding
- prophylactic abx for suspected variceal bleeding in pt w /cirrhosis (prevention of spontaneous bacterial peritonitis)WH
what is hermostasis?
GI bleeding stops spontaneously in roughly 80% of patients
specific hemostatic therapy depends on bleeding site
