GI Bleed Flashcards
How does upper GI bleeding (UGIB) usually present?
As hematemesis (blood or coffee-ground emesis) or melena (black, tarry stool).
What is the most common presentation of lower GI bleeding (LGIB)?
Hematochezia (frank blood per rectum or red or maroon-colored stool).
What are the inpatient mortality rates for UGIB and LGIB?
UGIB is estimated at 10% and LGIB at 4%.
What are the goals for evaluating and managing a patient with possible GI bleeding?
To stabilize the patient, confirm the gut is the origin of the bleeding, determine the likely site and nature of the bleeding, and provide appropriate therapy.
What was the trend in hospitalizations for GI hemorrhage related to peptic ulcer disease (PUD) from 2000 to 2011?
Decreased by 66% in the United States, mainly due to antimicrobial treatment for Helicobacter pylori.
What is a significant risk factor for PUD-associated bleeds?
Nonsteroidal antiinflammatory drug (NSAID) use.
What does UGIB originate from?
Proximal to the ligament of Treitz.
What are the most common causes of UGIB?
Peptic ulcer disease (PUD), erosive disease, and esophageal varices.
What are common causes of UGIB in children?
Mallory-Weiss tears, ulcers, gastritis, and esophagitis.
What does LGIB originate from?
Distal to the ligament of Treitz.
What is the most common cause of bleeding from the large bowel?
Diverticulosis.
What are common causes of pediatric LGIB?
Anal fissures, Meckel diverticulum, allergic colitis, enteric infections, and polyps.
What clinical indicators are more reliable than emesis color for gauging bleeding severity?
Clinical indicators of shock.
What symptoms may indicate significant blood loss?
Lightheadedness and atypical symptoms of acute coronary syndrome (ACS).
What signs should be assessed in patients with acute GI bleeding?
Signs of shock, including tachycardia and hypotension.
What initial lactate level is associated with increased mortality?
Greater than 2.5 mmol/L.
What does an INR greater than 1.5 indicate?
Increased inpatient mortality and the need for intensive care unit (ICU) admission.
What is the preferred imaging modality for significant UGIB?
Endoscopy.
What is the role of angiography in LGIB?
It can localize and embolize bleeding sources in unstable patients.
What is the sensitivity of nuclear scintigraphy for detecting bleeding?
It can detect bleeding as slow as 0.05 mL/min but is not indicated in acute GI bleeding.
What is the first step in managing patients with acute UGIB?
Determining if the patient is having a massive GI bleed or not.
How is a massive GI bleed defined?
Ongoing active bleed (hematemesis or hematochezia) and a shock index of 0.9 or greater.
What is the primary goal of volume resuscitation in massive GI bleed?
Maintenance of adequate tissue perfusion.
What initial treatment should be given to patients with a massive GI bleed?
Placement of at least two large-bore IV catheters, infusion of crystalloids, and transfusion of uncrossmatched blood.
What is the recommended bolus infusion of crystalloids for massive GI bleed?
2 L over 30 minutes with a balanced isotonic solution.
What is the second step in the management of acute GI bleeding?
Attempting to localize the bleed as either UGIB or LGIB.
What characterizes high-risk patients with GI bleeding?
Ongoing bleeding requiring interventions such as endoscopy, surgery, or continued blood transfusion.
What does a Glasgow-Blatchford score of 7 or greater indicate?
80.4% sensitivity in predicting the need for endoscopic treatment.
What is the significance of a Glasgow-Blatchford score of 1 or less?
Identifies patients at low risk of rebleeding who may be appropriate for discharge.
What does empiric treatment for acute GI bleeding involve?
Prompt resuscitation, consideration of blood or platelet transfusion, pharmacologic therapy, and early consultation.
What is the goal for crystalloid fluid infusion in patients showing signs of hemodynamic compromise?
Deliver 2 L over the first 30 minutes.
When should intubation be considered in patients with massive UGIB?
For patients with uncontrollable hematemesis, respiratory distress, or severe shock.
What is the recommended hemoglobin threshold for transfusion in stable patients without CAD?
At least 8 g/dL.
What is the recommended transfusion threshold for patients with known CAD?
Minimum hemoglobin greater than 9 g/dL.
What is the role of fresh frozen plasma (FFP) in patients with liver disease and GI bleeding?
Controversial; not recommended unless receiving massive transfusion.
What is the recommended platelet count to maintain in patients with UGIB?
Greater than 50,000 platelets/μL.
What is the mainstay pharmacologic therapy for acute GI bleeding?
Proton pump inhibitors (PPIs).
What is the recommended dose of IV omeprazole for acute GI bleeding treatment?
80 mg IV followed by a continuous infusion of 8 mg/h.
What agents are recommended for patients with variceal bleeding?
Splanchnic vasoconstrictors such as somatostatin and octreotide.
What prophylactic antibiotics are recommended for patients with UGIB and cirrhosis?
Fluoroquinolones or a third-generation cephalosporin.
What is the purpose of balloon tamponade in GI bleeding management?
Indicated for rapidly exsanguinating patients when endoscopy is not promptly available.
What should be done for patients with significant UGIB requiring early consultation?
Consultation with a gastroenterologist for consideration of endoscopy.
What is the recommendation for patients with brisk LGIB?
Emergent consultation with an interventional radiologist for possible selective embolization.
Common causes of GIB in adults and children
Diagnostic and management algorithm for acute GIB
Describe Glasgow-Blatchford Score
What is Heyde’s syndrome?
Heyde’s syndrome is a rare condition that causes aortic stenosis and gastrointestinal bleeding. A clinical triad of severe aortic stenosis, a history of recurrent gastrointestinal bleeding, and an endoscopic diagnosis of angiodysplasia
Causes of Pediatric GIB
Mimickers of GI bleed
What labs to send for GI bleed evaluation?
CBC, lytes, urea (BUN), Cr, albumin
LFT’s, lipase
inr, ptt
Group + screen
Vbg + lactate
TROP + ECG
± calcium, fibrinogen
At what ratio is BUN/Cr specific for GIB
blood urea nitrogen (BUN) to creatinine (Cr) ratio of greater than 35 is
90% specific for UGIB
However, the BUN:Cr ratio is poorly sensitive and
cannot be used to rule out UGIB
How does FOBT work?
Name some false positives and negatives.
When hydrogen peroxide drips onto guaic paper, an oxidative reaction turns the paper blue. uses the pseudoperoxidase activity found on Hb
Blood = blue
False positives: Colchicine, iodine, boric acid, red meat
False negatives: Vit C, Citrus fruits
Imitators of melena: iron, bismuth and black foods like black licorice
Order of priority of IV medications in upper GI bleed emergencies
- Ceftriaxone 1 g IV for all cirrhotics
- Octreotide 50 μg bolus + 50 μg/hr infusion for all UGIB patients
- Erythromycin 250mg, 30 minutes prior to endoscopy for suspected peptic ulcer
- PPI e.g. Pantaprazole 80 mg IV bolus (no infusion necessary) – once you’ve given everything else, if the endoscopist asks for it
Antibiotics have mortality benefit, NNT 22 for death, NNT 4 for infection
Octreotide is splanchnic vasoconstrictor prevents rebleeding both variceal and non variceal bleed
Erythromycin improves gastric motility and visualization of GI mucosa, NNT 10 to prevent repeat endo
PPI has no mortality benefit
Management steps in GIB
Airway Mx in UGIB
Complications of Massive Transfusion Protocol
Definition:Massive transfusion was traditionally defined as the administration of
more than 10 units of PRBCs over 24 hours, but a more practical and
efficacious application of the concept is the transfusion of 3 units of
PRBCs over an hour or the use of 4 components over 30 minutes.
What are the different types of tubes used in GIB ?
What are the indications and contraindications for using ballon tamponade in GIB?
Common complications of ballon tamponade
Characteristic of patients with high risk for GIB
What is Oakland score?
Used in patients with LGIB to help determine safe discharge home
What is the low risk criteria for d/c home?
Common reversal agents for bleeding
Commonly used plasma products
