GI bleed Flashcards
case: lots of conditions, afib
epigastric abdominal pain
no black tarry stool
chronic or acute?
probably acute due to concerning vitals: hypotensive, tachy
if chronic would have compensated
INR: on warfarin
CBC: hgb
1st things to do:
fluid (L bolus)
type/screen for blood transfusion
General approach to the GIB
Acute or Chronic?
Hemodynamic instability? ICU if not stable
Medications? OTC? (clopidogrel, warfarin, ASA, etc.) (new drugs: difficult to reverse)
Alcohol use?
Rectal exam? (bright red blood?) NG lavage? (blood? coffee grounds?: UGIB)
can reverse warfarin with
FFP and vitamin K+ (long term)
GIB tx
Fluids, +/- PRBC (blood transfusion), hold BP Rx, PPI, serial H+H, GI consult, No anticoagulants
coffee ground emesis
slide 5, blood, acidity turns it black
GIB background/terms
Is this acute or chronic?
Yes, HGB can be as low as 4 without any obvious hemodynamic instability
Hematemesis – bright red blood in vomit, or coffee ground type material
Melena – black, tar like stool
250,000 hospitalizations a year for acute upper GIB
Mortality 4-10%
Hematochezia – BRBPR (bright red blood per rectum) usually lower, but if
Massive upper GIB, can have this
osteopathic
esopagus: T2-T8
upper GI: T5-T9, Greater Splanchnic Nerve Celiac Ganglion
middle GI: T10-T11, Lesser Splanchnic Nerve Superior Mesenteric Ganglion
lower GI: T12-L2, Least Splanchnic Verse Inferior Mesenteric Ganglion
Acute Upper GI Bleed
Peptic Ulcer Disease: H. pylori
Portal Hypertension:
10-20% of cases
Can be massive due to esophageal or gastric varicose (problem if rupture, can bleed out)
Hemodynamic Stabilization
BP Systolic less than 100: high risk
HR greater than 100 response to acute blood loss, first vital sign of change (UNLESS on B-blocker)
HCT takes 24-72 hours to equilibrate (trust your gut! pt may have normal levels but look very sick)
initial steps
NG tube? Gastric Lavage? Rectal? Hemodynamic Stabilization Two large 18 gauge IV’s Type and Screen, CBC, INR/PT/PTT, CMP 0.9%NS until blood ready, if needed can use O – blood universal donor ICU? Central line?
HGB goal: old guideline HGB: 10, too many risks from blood transfusions
new guidelines:
7 is threshold now, unless cardiac history then consider goal of greater than 9 (if having brisk bleed with complications, look at pt not numbers)
Platelets more than 50,000
Warfarin? INR high? Give FFP
Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC
Uremia? (platelets there but don’t stick well together) ESRD Patient?
Consider DDAVP: promotes platelet adhesion
Warfarin? INR high?
give FFB
with simple transfusion may dilute out clotting factors: Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC
vitamin K+ long term
hx items
Aspirin?
NSAIDS?
NOAC? (?? anticoagulants)
Cirrhosis? (esophageal varices)
WHEN WAS THE LAST DOSE TAKEN?
clopidigrel, ASA take 10-14 days to get out of system (irreversibly bind)
Role of Upper endoscopy
Stabilize patient first hemodynamically
if see bleeding vessel, clip it
Cautery, injection, endoclips (fall off on own)
Banding varices (left picture)
video: cauterize with epi
pharm therapy
IV PPI: Bolus then drip for 72 hours
Consider PO PPI if low risk features (pantoprazole)
Octreotide
Octreotide
Patient’s with esophageal or gastric varices, liver disease, portal HTN
Reduces splanchnic blood flow and portal blood pressures (IV not oral)
PPI long term SEs
Potential decrease in non heme iron absorption with PPI has not been well studied
No good evidence to support PPI use affecting bone density or osteoporosis related fractures
~50 cases of hypomagnesemia associated with PPI use
(FDA recommended consider checking magnesium level before starting long term PPI therapy)
acute lower GIB
Hematochezia
10% due to upper source
Definition: below ligament of Treitz
diverticulosis
can erode into BV and cause bleeding
Acute, painless, large volume possible
antioectasia
More common in CKD/ESRD patients
other causes of acute lower GIB
Neoplasms
IBD
Anorectal disease (hemorrhoids, fissures)
Ischemic Colitis (older, nonocclusive ischemia, usually self limited)
Radiation induced proctitis
L GIB
Exclude upper GIB: NGT, lavage
Rectal Exam
Colonoscopy or sigmoidoscopy: Prep with GoLYTELY 3.8L
L GIB dx test: NM PRBC Scan
someone bleeding and don’t know where coming from
acts as tracer that will light up with active bleed
If positive, next step is angiography (interventional; can embolize)
Localization is poor, and only helpful if active bleed
L GIB dx test: Push Enteroscopy or Capsule Study
successive pictures
sx??
L GIB is typically
obscure
know slide 20
Crohn’s vs UC
Crohn’s
terminal ileum "skip" lesions; irregular transmural inflammation crampy abd. pain complic: fistulas, abscess, obstruction XR: string sign w. barium slight increase colon ca risk sx: for stricture complications
UC
rectum proximally continuous submucosal, mucosal inflammation bloody diarrhea complic: hemorrhage, toxic megacolon XR: lead pipe colon on barium XR *huge risk of colon Ca* (colonoscopy every few years) sx is curative
transfusions in acute upper GIB
Restrictive strategy group threshold of 7 g/dl
Goal 7-9
Liberal group threshold of 9 g/dl
Goal 9-11
Mortality at 45 days lower in restrictive strategy group 23/444 vs. 41/445
Subgroup with cirrhosis, risk of death was lower in restrictive strategy group 15/139 vs. 25/138
Novel Anticoagulants in GIB
Pradaxa – dabigatran
Xarelto – rivaroxaban
Eliquis - apixaban
expensive, but do not have to check INR!
active w.in hrs (vs. coumadin)
advantage if bleeding, wear off quickly as well
3 meds work as factor Xa inhibitor
??inhibit thrombin
diff than warfarin
Pradaxa – dabigatran blocks thrombin
novel anticoagulants
risk of GIB is a little higher
hemorrhagic stroke risk is lower
When to Resume Warfarin After GIB
7 days
Restarting warfarin after 7 days was NOT associated with increased risk of GIB, but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption.
sometimes elderly pts on steroids/NSAIDS put on pentoprozol? to ??
prevent risk of bleed
sometimes don’t want to go on due to risk of C. diff
recommendations for ASA
Use of low dose aspirin for cardiovascular prophylaxis associated with 2-4 fold increase in upper gastrointestinal events (81 mg just as effective as 325 mg, less GIB risk)
AHA recommends low dose aspirin in patient with 10 year cardiovascular risk > or = 10%
INR goal of 2-2.5 is recommended for:
Combination of aspirin and heparin/LMWH/warfarin or clopidogrel
which ulcer more pain with eating??
what else?
Gastric ulcer – Greater with meals (pain)
Duodenal ulcer – Decreases with meals (pain)
Ischemic colitis – post-prandial abdominal pain, older patient, hematochezia
medications
H2 blockers – famotidine, ranitidine – Block H2 receptors of parietal cells
PPI’s – omeprazole, pantoprazole (high risk C.diff) – Inhibit H+/K+ ATPase in parietal cells
? Low magnesium levels long term use, higher risk of C diff
Magnesium – Makes you go, take for constipation
Aluminium – minimum amount of feces, take for diarrhea
Osmotic laxatives – PEG, lactulose
