GI Bleed (Exam 2) Flashcards
Patient presentation of a GI bleed varies by
site of bleeding within GI tract
rate of blood loss
Upper GI bleed
bleeding proximal to ligament of treitz
esophagus, stomach, proximal duodenum
Lower GI bleed
bleeding distal to ligament of treitz
small intestine, large intestine, anus
Ligament of treitz
smooth muscle connecting diaphragm to duodenum
what is the most common cause of a GI bleed?
peptic ulcer disease
non-variceal (acid related) etiology of UGIB
PUD
SRMD
variceal etiology of UGIB
portal hypertension in liver disease
etiology of LGIB
IBD
colon cancer
diverticulitis
hemorrhoids
infectious disease
treatment of GI bleed is geared towards
underlying cause
patient presentation in GI bleed
blood in stool
bloody diarrhea
vomiting blood
nausea
abdominal pain
lightheadedness/dizziness, syncope, angina or dyspnea
hematemesis
vomiting up blood
upper GI bleed
melena
dark, tarry stools
upper GI bleed
hematochezia
passage of bright red blood in stool
lower GI or upper GI bleed
hematochezia can indicate upper GI bleed in cases of
quick bleeding
treatment goals of GI bleed
identify and treat/remove source of bleed
achieve hemostasis and prevent rebleed
maintain hemodynamic stability
prevent complications
what type of IV fluids are recommended if a patient is hypotensive
crystalloids (0.9% NaCl, lactated ringers)
when is intubation recommended during a GI bleed?
severe ongoing hematemesis
altered mental status
blood transfusion follows a
restrictive transfusion policy
give a blood transfusion when Hgb is less than
7 g/dl
1 package unit of RBC results in
Hgb increased by 1 g/dl
Hct increase of 3-4%
when considering blood transfusion, consider
rate of blood loss
predicted drop in blood loss
clinical status
you don’t need to wait to transfuse if
rapid blood loss
preferred scoring tool for risk of rebleed
Glasgow Blatchford score (GBS)
score of GBS ranges from
0-23
low risk score for GBS
high risk score for GBS
low - 0-1
high - score above 1
GBS score for outpatient management
0-1
endoscopy
visualization of GI tract with endoscope
test of choice to evaluate UGIB
esophagogastroduodenoscopy (EGD)
test of choice to evaluate LGIB
why?
colonoscopy
it evaluates the entire colon and rectum
perform endoscopy within ___________ of admission for UGIB
24 hours
do not delay endoscopy in patients on
anticoagulants
what is suggested before endoscopy in UGIB and why
erythromycin transfusion
enables better visualization
high risk features
active bleeding or visible vessel
intermediate risk features
adherent clot
low risk features
flat pigmented spot or clean base
high risk therapy
endoscopic therapy and high dose PPI
intermediate risk therapy
yes/no endoscopic therapy and high dose PPI
low risk therapy
no endoscopic therapy and standard PPI therapy
what is the treatment of choice in non-variceal UGIB
PPIs
high dose PPI therapy days 1-3
continuous therapy: 80 mg IV bolus then 8 mg/hr continuous infusion
intermittent therapy: oral/IV 80mg bolus then 40mg BID-QID IV or PO
High dose PPI therapy days 4-14
twice daily PO PPI
high dose PPI therapy days 15+
once daily PO PPI
standard PPI therapy
give an oral PPI once daily
Intravenous PPIs
pantoprazole
esomeprazole
patient should be discharged with
once daily oral PPI
stop medications that may have caused bleed until
benefit outweighs risk
examples of medications that should be stopped
NSAIDs
antiplatelets
anticoagulants
aspirin - primary CVD prevention
should aspirin be stopped if a patient with a GI bleed takes it for secondary CV prevention?
why?
no
no significance in difference of bleeding or mortality
when changing NSAIDs,
if needed COX2 inhibitor or other class drug and PPI
when changing anti platelet therapy
clopidogrel, prasurgel, ticagrelor, aspirin
and PPI
when changing anticoagulant therapy
warfarin, apixaban, rivaroxoaban, dabigatran
and PPI
which PPIs does clopidogrel interact strongly with?
weakly?
esomeprazole and omeprazole
pantoprazole and rabeprazole
PPIs inhibit ______________ which blocks ____________
CYP2C19
clopidogrels effects
which PPIs would you want to use if the patient is on clopidogrel
consider pantoprazole or rabeprazole
Stress ulcer prophylaxis should be given to
high risk ICU patients only
STOP WHEN NO LONGER HIGH RISK!!
