GI bleed Flashcards
suspect non GI causes of. melena or blood in stool (3)
beet ingestion
iron
Pepto-Bismol
risk factors for GI bleed
previous bleed
ICU admission
NSAIDs
alcohol
if pt at risk for GI bleed, start
cytoprotection (PPI)
R/O serious cause of GI bleed (4)
Lower:
malignancy
inflammatory bowel disease
Upper:
ulcer
varices
DDx LGIB bleed 6 + 3
Diverticulosis - most common
Angiodysplasia
Colitis
Inflammatory bowel disease
Infectious
Neoplastic or polyps
Anorectal (hemorrhoids, anal fissures, rectal ulcers)
DDx UGIB bleed 6
Peptic ulcer
Esophagogastric varices
AV malformations
Tumor
Esophageal (Mallory-Weiss) tear
Esophagitis/Gastritis
associate the following risk factors with outcome
H Pylori, smoking, NSAIDs
H Pylori, smoking, alcohol
H pyulori and smoking both
and
NSAIDS - Peptic ulcer disease
ROH: Malignancy
give the diagnosis
Epigastric or right upper quadrant pain
Peptic ulcer:
give the diagnosis
Odynophagia, gastroesophageal reflux, dysphagia
Esophageal ulcer
give the diagnosis
Emesis, retching, or coughing prior to hematemesis
Mallory-Weiss tear
give the diagnosis
Jaundice, weakness, fatigue, anorexia, abdominal distention
Variceal hemorrhage or portal hypertensive gastropathy:
give the diagnosis
Dysphagia, early satiety, involuntary weight loss, cachexia
Malignancy
INvestigations
CBC (Hb, platelets), Chem (BUN, creat), Liver enzymes (AST, ALT), Coag (INR), Albumin
EKG, Troponin
if risk of MI (older, hx of CAD, chest pain or dyspnea)
Type and Screen or Cross-match if risk
treatment (8)
MOVIE
Oxygen, monitor, BP cycle
NPO
Two large IVs
NG + Elective endotracheal intubation if ongoing hematemesis, altered mental status, or risk of aspiration
Fluid resuscitation
antibio if variceal bleeding (ceftri 1g IV)
PPI
Prokinetic - Promotes gastric emptying, shown to reduce second endoscopy
somtostatin if variceal bleeding
antiplatelet agents reversal prn
when to transfuse
Hb >70g/L (consider >90g/L if massive bleeding or comorbid eg. CAD)
Avoid overtransfusing patients in variceal bleeding - can worsen bleeding
Consider platelets, plasma if receiving massive RBC transfusions
posology PPI
Omeprazole 40mg IV BID or Pantoloc 40mg IV BID
Pantoloc 80mg bolus and 8mg/h drip has not been shown to be superior
Prokinetic example
Promotes gastric emptying, shown to reduce second endoscopy
Consider Erythromycin 3mg/kg or 250mg IV over 30 mins (30 mins-90mins prior to endoscopy)
what to give if suspected variceal bleeding (eg and posology)
Somatostatin (and analogs) in suspected variceal bleeding, however may have a role in nonvariceal bleeding in settings where endoscopy is unavailable
Octreotide 50mcg IV bolus then 50mcg/hour
antiplatelet agents reversal prn 3
Warfarin → Vitamin K
Heparin → Protamine, Fresh frozen plasma
Dabigatran → Praxbind (Idarucizumab)
uncontrollable hemorrhage tx
intubation
+ balloon tamponade
