GI Bleed

Question 1

Risk Factors

Answer 1

ETOH MC

NSAIDs, ASA

steroids

coumadin/heparin/thrombolytics

cirrhosis (dec synthesis of clotting factors)

esophageal varices due to portal HTN

blood dyscrasias

Question 2

Sources of GI Bleeding

Answer 2

Upper: above ligament of Treitz

Lower: below ligament of Treitz

Ligament of Treitz separate duodenum from jejunum

Question 3

Upper GI Bleeding Sources

Answer 3

Epistaxis or oral lesions

Esophageal Varices (commonly rebleed)

Mallory-Weiss syndrome (bleeding from superficial tear in mucosa from repeated vomiting)

Esophagitis/Gastritis

Gastric/Duodenal Ulcer (MC cause of upper GI bleed)

Question 4

Lower GI Bleed Sources

Answer 4

Upper GI Bleed (melena)

Carcinoma (CRC)

Diverticulosis (MC cause)

Angiodysplasia/Arteriovenous malformation

Infectious diarrhea

IBD

Hemmorrhoids/Anal fissure

Question 5

History

Answer 5

Hematemesis/coffee ground emesis suggest UGI source

Melena suggests proximal to right colon

Hematochezia suggests distal colorectal lesion

Hx of previous bleed–often a recurrence

Weight loss, change in bowel habits

Vomiting followed by hematemesis (Mallory Weiss)

Alcohol use

Meds: Iron adn bismuth can simulate melena, beets can stimulate hematochezia, stool guaiac will differentiate

Question 6

PE

Answer 6

May have sublte changes:

hypotensive, tachycardiac (check orthostatic v/s)

decreased pulse pressure

tachypnea

Skin:

• cool, clamy–shock
• jaundice, palmar erythema, spider angioma–liver disease and ETOH
• petechia/purpura–coagulopathy

ENT: check for oral/nasal source of bleeding

Question 7

Lab

Answer 7

CBC

PT/PTT, platelets

Electrolytes, BUN/Cr, BG

LFT

EKG if suspect underlying CAD

Question 8

Radiographic Studies

Answer 8

Lower GI contrast study like Ba enema; can’t use acutely

Technecium-labeled RBC scan–very sensitive for detecting GI bleed. Good when cannot localize bleed with endoscopy

Angiography–less sensitive but can embolize or vasoconstrict to control bleeding

Question 9

Management

Answer 9

Primary

• ABC’s
• Volume replacement
• NG tube placement
• Potentially transfuse blood

Secondary

• Endoscopy–identify and control bleeding
• Drug therapy–vasoconstrictors to try to stop bleeding
• Balloon tamponade (Sengstaken-Blakemore tube)

Surgery if medical and endoscopic interventions fail