GI - Bleed

Question 1

80% of UPPER G.I. bleed are caused by?

Other causes?

Answer 1

#Peptic ulcer - 30%
#Esophageal varices - 30%
#Erosive esophagitis - 8%
#Mallory-Weiss tear - 6%

Erosion, tumor, portal gastropathy, esophageal ulcer, Cameron lesion, Dieulafoy’s lesion, AV fistula, Hemobilia,

Question 2

Appreciate tumors associated with bleeding?

Answer 2

Esophageal, gastric, GIST

Question 3

Causes of BRISK upper G.I. bleed?

Answer 3

#Peptic ulcer
#Varices
#Dieulafoy's lesion
#Aortoenteric fistula
#Hemobilia (usually procedural)
#Neoplasm
#Hemosuccus pancreaticus (aneurysm/#pseudoaneurysm)

Question 4

Predictors of severe G.I. bleed?

Answer 4

#Hematemesis
#Comorbidities (cirrhosis, malignancy)
#Hemodynamic Instability
#Hemoglobin under 8

Question 5

When to manage UPPER G.I. bleed as an outpatient?

Answer 5

Glasgow-Blatchford score

#BUN under 18
#Normal hemoglobin
#Systolic blood pressure over 109 
#Heart rate under 100
#No melena, syncope,
#No history of liver disease, cardiac failure

(none of these things, 100% negative predictive value for severe G.I. bleed)

Question 6

Upper G.I. bleed most reliably predicted by which individual variables?

Answer 6

#Melena
#Nasogastric lavage with blood
#BUN: creatinine over 30
#Absence of blood clots in the stool

Question 7

Pre-endoscopic Management of UPPER G.I. bleed? REDO

Answer 7

#Crystalline resuscitation until HR100
#transfusion if hemoglobin 1.5
#Octreotide and anabiotics if suspected variceal bleeding

Question 8

Patient with upper G.I. bleed – would delay endoscopy if?

Answer 8

INR>3

Question 9

Went to get urgent (within 12 hours) endoscopy?

Answer 9

Suspected variceal bleeding

Question 10

Treatment of low risk versus high risk ulcers after endoscopy?

Answer 10

Oral PPIS, PO intake, and early hospital discharge

Hospitalization and IV PPI therapy for 72 hours

Question 11

Strongest predictors of bleeding after endoscopic therapy for ulcers?

Answer 11

#Autonomic instability
#Active bleeding at endoscopy
#Ulcer over 2 cm
#Ulcer location in posterior duodenum or lesser gastric curvature

#Age over 60
#Hemoglobin under 10

Question 12

When to do repeat endoscopy?

Answer 12

After 8-12 weeks after PPI therapy if:
#Symptoms persist
#Concern for underlying malignancy
#Incomplete visualization of the stomach
#Biopsies were not taken initially

Question 13

All patients with upper G.I. bleed due to ulcers should be tested for? If negative?

Answer 13

H pylori

Retest (due to false negative possibility in the setting of bleeding, PPI)

Question 14

Post upper G.I. bleed, should anticoagulation be restarted?

Answer 14

#Restart aspirin within 3 to 5 days in patients with cardiovascular disease
#If bare metal stent, restart aspirin but hold Plavix temporarily for high-risk ulcers
#If DES, restart Plavix immediately for low risk ulcers and as soon as possible for high risk

Question 15

Patient with upper G.I. bleed s/p eradication of H pylori. On aspirin – necessity of long-term PPI?

Went to begin long term PPI?

Answer 15

Not necessary

#GI bleed and H pylori negative
#Use of NSAIDs, anticoagulants, glucocorticoids, or Antiplatelet therapy

Question 16

Patients with thrombotic risk should receive re-anticoagulation after G.I. bleed if?

Answer 16

#atrial fibrillation with previous embolic event
#CHADS score 3+
#Recent ACS
#Mechanical heart valve
#DVT/PE

Question 17

How to restart anticoagulation on a patient with recent G.I. bleed but high thrombotic risk?

Answer 17

Bridging

OR

Begin oral anticoagulation 7 days after bleeding event

Question 18

80% of lower G.I. breeds are caused by?

Other causes?

Answer 18

#Diverticulosis - 30%
#Colitis (ischemic > IBD > radiation > infectious) - 24%
#Hemorrhoids - 14%
#Post polypectomy bleeding - 8%

Polyps, cancer, rectal ulcer, angiodysplasia, Aortoenteric fistula, intussusception, Meckel diverticulum, Dieulafoy’s

Question 19

Causes of severe lower G.I. bleeding?

Answer 19

#Diverticulosis
#Colitis
#Aortoenteric fistula
#Colonic/rectal varices
#Neoplasm
#Intussusception
#Meckel diverticulum
#Angiodysplasia

Question 20

Lower G.I. bleed and pain – differential?

Answer 20

#Colitis (ischemic, IBD, radiation, infectious)
#Drugs (NSAIDs)

Question 21

When to manage LOWER G.I. bleed as an outpatient?

Answer 21

#Age under 60
#Hemodynamic stability
#No gross rectal bleeding
#Obvious anorectal source on rectal exam/sigmoidoscopy

Question 22

Blood transfusion threshold for patients with colonic bleeding?

Answer 22

Hemoglobin if 9

Question 23

When to scope patient with lower G.I. bleed?

Answer 23

#Generally after 24 hours
#Within 12-18 hours if rebleeding

Question 24

P82

Answer 24

P82

Question 25

Dieulafoy lesion?

Cameron lesion?

Answer 25

Large tortuous, submucosal arteriole (Usually in the gastric Cardia) that erodes and bleeds

Erosions found in 5% of large hiatal hernias