GI bleed - GI

Question 1

Risk Factors

Answer 1

• NSAIDs, aspirin
• Steroids
• Coumadin/Heparin/Thrombolytics
• Alcohol
• Cirrhosis (defective synthesis of clotting factors)
• Esophageal varices due to portal hypertension
• Blood dyscrasias (thrombocytopenia, leukemia, etc.)
• Hemophilia, vonWillebrand’s, etc.

Question 2

Sources of GI Bleed

Answer 2

• Upper: above ligament of Treitz

- Lower: below ligament of Treitz

Question 3

Upper GI bleed sources

Answer 3

• Epistaxis/oral lesions
• Esophageal varices: Most likely to rebleed: 40-70%
• Mallory-Weiss syndrome
• Esophagitis/Gastritis
• Gastric/Duodenal Ulcer: Most common cause of UGI bleed: about 50%, About 10% rebleed

Question 4

Lower GI Bleed Sources

Answer 4

• Upper GI bleed: causes apparent lower GI bleed
• Carcinoma
• Diverticulosis: Most common cause of true lower GI bleed
• Infectious diarrhea
• Inflammatory bowel disease (Crohn’s, ulcerative colitis)
• Hemmorrhoids/anal fissure

Question 5

History can help point to source of bleed

Answer 5

• Hematemesis/coffee ground emesis suggest UGI source
• Melena suggests source proximal to right colon
• Hematochezia suggestions more distal colorectal lesion
• Exceptions occur!

Question 6

Management : Acute GI Bleed

Answer 6

Primary management

• High flow oxygen
• Possible intubation for airway control if profuse UGI bleed
• Cardiac monitor
• Volume replacement, large bore IV lines
• Begin with crystalloid (normal saline or LR)

Transfuse blood if:

• Continued active bleeding
• Severe anemia
• Failure to improve after 2 liters of crystalloid
• Replace coagulation factors as needed (FFP, platelets)

Question 7

Management : Acute GI Bleed - secondary management

Answer 7

Upper endoscopy

• Most accurate technique to identify source of UGI bleed
• Can achieve hemostasis via sclerotherapy, electrocoagulation, heat probes, laser, banding varices

Sigmoidoscopy/Colonoscopy
-Can diagnose LGI bleed source, intervene at bleeding site

Proctoscopy/Anoscopy
-Identifies anorectal source of bleeding (e.g., hemorrhoids)

Drug Therapy
-Vasopressin (IV or intra-arterial), octreotide: vasoconstrictors. -Side effects: hypertension, myocardial ischemia, arrhythmia)
H2 agonists, proton-pump inhibitors (questionable benefit)

Balloon Tamponade: Sengstaken-Blakemore tube

• Useful for controlling significant UGI hemorrhage
• Gastric and esophageal balloons inflated to tamponade source of bleed

Surgery
-Indicated if medical and endoscopic interventions fail