GI Bleed, GIBiome, C.diff

Question 1

Who gets GI bleeds?

Answer 1

Male
MC emergent indication for GI endoscopy EGD
Mortality LC- bleed continues and reoccurs
4 out 5 stop bleeding
Comorbid- Liver Dz, Portal HTN, cirrhosis

Question 2

What are causes of GI bleed?

Answer 2

MC-Duodenal ulcer
Gastric Ulcer
Varices 
Esophagitis
Demograph dependent

Question 3

How is assessment and management determined?

Answer 3

Hemorrhagic shock
Protection of Airway
ASK- LFTs and Platelet count
Anticoagulation
NSAIDs?
Smoking?

Question 4

Mr. Heme c/c is coughing up blood? What is initial management?

Answer 4

Determine blood type and cross blood
CBC/BMP
NGT
2 Large bolus NS IVs
HgB is Key
PT INR
O2 monitor

Question 5

Mr. Heme has lost 1/2 of his blood? What is concern with Hgb

Answer 5

losing 1/2 Hgb will be the same
Hgb concentration/vol
If normal, still means GIB

Question 6

What is dependent on mortaility?

Answer 6

Location in Hosp.
Floor, Home, ICU
Scope fast

Question 7

What are highest risk of death

Answer 7

1. Shock, red blood; low BP
2. varices or cancer very bad
3. Comorbid disease
4. Older age
5. Onset in hospital
6. Recurrent bleeding

Question 8

Mr. Heme had 12 unit of transfusion and PMH of chirrosis? What is death dependent on regarding units?

Answer 8

INC unit amount, INC cormorbid= HIGH mortality rate

Question 9

What has the highest risk of rebleed and death?

Answer 9

Varices

Dilated tortuous veins w/in GI, esophagus*, etc

Question 10

When are Nasogastric tubes placed?

Answer 10

Eval of GIB
DX- if W/D of blood
DX- severity and type bleed, coffee grounds, BRB, negative

Question 11

What allows for clearance of stomach which can, reduce risk of aspiration, Clears the view for EGD?

Answer 11

Nasogastic Tube
Easy to place
Uncomfortable
False Neg
INC risk for sinusitis
INC risk into bronchus

Question 12

If blood get activated by bacteria in colon, and indicates initial bleed was high in GI tract? What color is stool?

Answer 12

Black Melena
tarry stools
Oxidized of iron on Hgb
Amount 50-100cc/mL

Question 13

What color determines HUGE amount of blood in UGIB, and high risk based of NG eval?

Answer 13

Bright Red

30% mortality

Question 14

How long can melena be present b4 seeing stool?

Answer 14

Week
MC is UGI source
Acute

Question 15

What are risk if NG aspirate types of color of blood?

Answer 15

NG Red w/ Red stool 30%- EMERGENT
NG coffee ground w/ Red stool 20%
NG Red w/ Blk stool 12%

NG coffee ground w/ Black stool 9%
NG Clear w/ Red stool 7%
NG Clear w/ Black stool 5%

Question 16

What will Endoscope provide for treatment of GIB?

Answer 16

Location
Severity- level of care
Acute vs Chronic
Eitology-TX, DX, Prognosis

Question 17

What is the MC cause of UGIB?

Answer 17

Pelvic ulcer dz- artery

Gastric MC

Question 18

Mr. Heme was taking NSAID due to his PMH of PUD. He was DX w/ H. pylori. Nothing was helping so he took NSAIDs due to pain. He also had PHM of cirrhosis and GERD? What are the his risk for PUD?

Answer 18

NSAIDs/ Aspirin
Helicobacter pylori infection
Physiologic Stress- life threatening illness)
Gastric Acid

Question 19

Mr. Heme had a rebleeding, which of the following Stigmata posed 43% risk of rebleeding? 
Clean base
Flat spot
Adherent clot
Non bleeding visible vessel
Active bleed.

Answer 19

Non-bleeding visible vessel

Ulcer size and location may also affect the re-bleeding potential.

Question 20

What is standard of care for PUD Upper GIB only?

Answer 20

Endoscopy Hemostasis
Triage and prognois
Dec Rebleed by 50%
NO affect on mortality

Question 21

How do you manage PUD

Answer 21

IV Access
Labs CBC, Platet, PT, PTT
LFT
Electrolytes
NPO-no meal by mouth
Resuscitation measures

Question 22

The following are at risk for what?
>60 
Comorbity
Hypotension
RED blood stool and scope- active or visible vessel
Shock
Prolonged PT/cirrhosis
Mental status

Answer 22

Risk for 
ICU surgery consults
Endoscopy 
Hemostatsis
Goal- prevent recurrent bleed

Question 23

Mr. Cherry has clean base, no comorbity. What is his management?

Answer 23

Treat Ulcer
Early d/c
Medical ward admission

Question 24

Why is it important to monitor pH in risk bleeder?

Answer 24

Low ph <7.4 reduced platelet aggregation
Clotting is PH dependent
Pepsin doesn’t work at pH of 1

Question 25

*What reduce rebleeding and surgery, but do not effect mortality?

Answer 25

PPI- proton pump inhibitors
IV 72h
PO BID 5d

Question 26

Which RX decrease ACID formation?

Answer 26

Histamine H2 receptor
PPI
STOP NSAIDs

Question 27

As a HCP what is goal used to stop bleeding when Endoscopy therapy fails?

Answer 27

Angiography

Question 28

What is other common cause of acute UGIB when Dilated veins occur due to portal HTN?

Answer 28

Acute Variceal Bleeding-30% mortality
MC w/ cirrhosis
AKA Varices

Question 29

Mr. Cherry is coughing up blood due to a varices? What is initial step?

Answer 29

Resuscitation
IV-somastostain
ABX

Question 30

**What should be initiated as soon as variceal hemorrhage is suspected and continued for 3-5 days after diagnosis is confirmed?

Answer 30

Octreotide in variceal bleed

1. induces selective splanchnic vasoconstriction
2. long acting analog of somatostatin
3. Inhibits release of vasodilator hormones like glucagon decreasing portal flow while increasing MAP
4. No clear cut impact on mortality

INpatient IV, ICU

Question 31

What are the MC of lower Gi Bleeds?

Answer 31

#1Diverticulosis
Unknown
Malignancy
Ischemic Colitis
IBD
Hemorrhoids
Post op- radiation 
Angiodyplasia

Question 32

What is reassuring to patient if they have rectal bleeding?

Answer 32

Colon cancer RARE doesn’t bleed

Question 33

What arteriovenous malformation is prone to bleeding?

Answer 33

teleangectasias- radiation proctitis

Especially after radiation

Question 34

What is a slow bleed from GI?

Answer 34

Occult GI Bleeding
Lab- 1. guaiac- non specific
2. FIT-Fecal Immunohistochemical Test- more specific for **human Hgb
**POSITIVE- colonoscopy

Question 35

What is used to examine bowels for Lower GI bleeds?

Answer 35

URGENT-Colonoscopy after prep

Enterscopy- long scope to examine if TUMOR in small bowels
VERY RARE
Length of small intestine to cecum 20FT