GI Bleed

Question 1

What anatomical landmark serves as the boundary between the upper and lower GI bleeds?

Answer 1

the ligament of treitz

Question 2

What are the initial actions you should take in a patient with a suspected GI bleed?

Answer 2

do primary survey
assess location and rate of bleeding
determine the need for blood transfusion
determine the need for correction of a clotting disorder

Question 3

What physical exam procedure can be done to help localize the source (upper or lower) of bleeding?

Answer 3

nasogastric aspiration

Question 4

Why is nasogastric aspiration necessary?

Answer 4

Although melena is usually upper and hematochezia is usually lower, you can get either with the opposite depending on the rate of bleeding and transit through the GI system, so you need to do nasograstric aspiration to know for sure

Question 5

In what scenarios should you consider transfusion in a patient with GI bleed?

Answer 5

1. massive upper or lower GI bleed (passing 1000 ml of marron-colored thin liquids stools every 20-30 min or NGT with steady bright red blood out)
2. Hgb droping >3 over 2-4 hours with active bleeding
3. Hemoglobin below 9 in setting of active bleeding
4. Anemia-induced end-organ injury

Question 6

What should you do in the setting of an active GI bleed and an elevated prothrombin time?

Answer 6

give FFP as the most rapid means of correction in addition to Vitamin K

Question 7

What should be given if the patient is also on heparin?

Answer 7

protamine (in addition to the FFP)

Question 8

A platelet transfusion should be performed in patients with severe GIB and a platelet count less than ____.

Answer 8

50,000

Question 9

What should be on the differential for upper GIB?

Answer 9

gastric and duodenal ulcers

gastritis and esophagitis

esophageal and gastric varices

mallory-weiss

aortoenteric fistula

Question 10

What should be on the differential for lower GIB?

Answer 10

diverticulosis
angiodysplasia
carcinoma
colitis (infections, ischemic, IBD)
Anorectal (hemorrhoids, fissurs)

Question 11

In a patient with severe upper GIB that cannot be controlled, unstable vital signs and no ability for emergent endoscopy, what should be considered?

Answer 11

esophageal tamponade with a sengstaken-blakemore tube

Question 12

What are the four general pharmacologic management options for GI bleed?

Answer 12

PPI
H2 blockers
somatostatins
antibiotics

Question 13

What are the option sfor PPI?

Answer 13

you can either give them IV BID dosing or do a continuous infusion of protonix if the patient has comorbidities that make them higher risk like liver failure

Question 14

Which patients should get the somatostatins like octreotide?

Answer 14

patients with known or highly suspected variceal bleeding

Question 15

Which patients should be given antibiotics?

Answer 15

if they have a history of cirrhosis (ABx have reduced mortality by 20%) because many will have an underlying bacterial infection