GI Bleed Harrison's Flashcards
_____ are the most common cause of UGIB, accounting for ~50% of cases.
Peptic ulcers
Mallory-Weiss tears account for ____% of cases
~5–10%
Approximately _______% of patients with bleeding ulcers will rebleed within the next year if no preventive strategies are employed.
10–50
Eradication of H. pylori in patients with bleeding ulcers decreases rates of rebleeding to ____%
<5%
The classic history is vomiting, retching, or coughing preceding hematemesis, especially in an alcoholic patient. Bleeding from these tears, which are usually on the gastric side of the gastroesophageal junction, stops spontaneously in 80–90% of patients and recurs in only 0–10%.
MALLORY-wEISS tears
hereditary hemorrhagic telangiectasias
Osler-Weber-Rendu
“watermelon stomach”
gastric antral vascular ectasia
are responsible for the majority of cases of obscure GIB.
Small-intestinal sources of bleeding
______ is the most common cause of significant small-intestinal GIB in children, decreasing in frequency as a cause of bleeding with age.
Meckel’s diverticulum
_____ are probably the most common cause of LGIB;
Hemorrhoids
______ bleeding is abrupt in onset, usually painless, sometimes massive, and often from the right colon;
Diverticular
Anatomic Separation of upper from lower GI Bleed
ligament of Treitz
Melena indicates blood has been present in the GI tract for at least ___ and as long as ____
14 h, 3–5 days.
Other clues to UGIB include _______ bowel sounds and an elevated blood urea nitrogen (due to volume depletion and blood proteins absorbed in the small intestine)
hyperactive
Treatment to improve endoscopic visualization with the promotility agent _______, 250 mg intravenously ~30 min before endoscopy, also may be considered: it provides a small but significant increase in diagnostic yield and decrease in second endoscopies but is not documented to decrease further bleeding or death
erythromycin
Current guidelines suggest _______ as the initial test for massive obscure bleeding, and _______, which allows examination of the entire small intestine, for all others.
angiography; video capsule endoscopy
Fecal occult blood testing is recommended only for colorectal cancer screening and may be used beginning at age __ in average-risk adults and beginning at age ___ in adults with a first-degree relative with colorectal neoplasm at ≥60 years or two second-degree relatives with colorectal cancer.
50; 40
UGIB=
LGIB= , or obscure GIB (if the source is unclear).
UGIB (esophagus, stomach, duodenum),
LGIB (colonic), small intestinal,
patients with clean-based ulcers have rates of serious r rent bleeding approaching zero.
T
Which are considered high risk ulcers?
high-risk ulcers = active bleeding, nonbleeding visible vessel, adherent clot
Randomized controlled trials document that high-dose, constantinfusion IV proton pump inhibitor (PPI) (80-mg bolus and 8-mg/h infusion), designed to sustain intragastric pH >6 and enhance clot stability, decreases further bleeding and mortality in patients with high-risk ulcers (active bleeding, nonbleeding visible vessel, adherent clot) when given after endoscopic therapy.
true
GOAL PH
> 6
Patients with lower-risk findings (flat pigmented spot or clean base) TX?
do not require endoscopic therapy and receive standard doses of oral PPI.
three main factors in ulcer pathogenesis,
Helicobacter pylori, nonsteroidal anti-inflammatory drugs (NSAIDs), and acid
Patients with bleeding ulcers unrelated to H. pylori or NSAIDs should remain on PPI therapy indefinitely given a 42% incidence of rebleeding at 7 years without protective therapy.
42% incidence of rebleeding
bLEEDING OF MALLORY-WEISS TEARS SPONTANEOUSLY STOPS IN _______ RECURS IN ____
stops spontaneously in 80–90% of patients and recurs in only 0–10%.
Urgent endoscopy within 12 h is r mended in cirrhotics with UGIB, and if esophageal varices are present, endoscopic ligation is performed and an IV vasoactive medication (octreotide, somatostatin, vapreotide, terlipressin) is given for 2–5 days.
tRUE
Long term tx for esophageal varies
nonselective beta blockers plus endoscopic ligation is recommended
When is TIPS (Transjugular intrahepatic portosystemic shunt) considered variceal bleeding
- persistent or recurrent bleeding despite endoscopic and medical therapy.
- considered in the first 1–2 days of hospitalization for acute variceal bleeding in patients with advanced liver disease (e.g., Child-Pugh class C with Child-Pugh score 10–13),
are endoscopically visualized breaks which are confined to the mucosa and do not cause major bleeding due to the absence of arteries and veins in the mucosa
EROSIONS
The most important cause of gastric and duodenal erosions is ——-:
NSAID use
~50% of patients who chronically ingest NSAIDs may have gastric erosions.
Stress-related gastric mucosal injury occurs only in extremely sick patients, such as those who have experienced
serious trauma, major surgery, burns covering more than one-third of the body surface area, major intracranial disease, or severe medical illness (i.e., ventilator dependence, coagulopathy).
an aberrant vessel in the mucosa bleeds from a pinpoint mucosal defect
Dieulafoy’s lesion
OTHER UGIB
prolapse gastropathy (prolapse of proximal stomach into esophagus with retching, especially in alcoholics), aortoenteric fistulas, and hemobilia or hemosuccus pancreaticus (bleeding from the bile duct or pancreatic duct).
The most common causes of Small-intestinal GIB in adults >40 years are
vascular ectasias
neoplasm (e.g., GI stromal tumor, carcinoid, adenocarcinoma, lymphoma, metastases)
NSAID-induced erosions and ulcers
Other causes in patients <40 years include
Crohn’s disease, polyposis syndromes, or neoplasm.
Less common causes of small-intestinal GIB include
infection, ischemia, vasculitis, small-bowel varices, diverticula, intussusception, Dieulafoy’s lesions, aortoenteric fistulas, and duplication cysts.
Small-intestinal vascular ectasias
rebleeding is common: 45% over a mean follow-up of 26 months in a recent systematic review.
Colonic diverticula stop bleeding spontaneously in ~80–90% of patients and, on long-term follow-up, rebleed in ~15–40% of patients.
true
Bleeding from colonic vascular ectasias may be overt or occult; it tends to be chronic and only occasionally is hemodynamically significant.
t
Patients with Heyde’s syndrome (bleeding vascular ectasias and aortic stenosis) appear to benefit from aortic valve replacement.
true
Transfusion is recommended when the hemoglobin drops below 7 g/dL, based on a large randomized trial showing this restrictive transfusion strategy decreases rebleeding and death in acute UGIB compared with a transfusion threshold of 9 g/dL.
the
Other clues to UGIB include hyperactive bowel sounds and an elevated blood urea nitrogen
elevated blood urea nitrogen (due to volume depletion and blood proteins absorbed in the small intestine).
Intensive PPI therapy
Intravenous bolus (80 mg) followed by infusion (8 mg/h) for 3 days; or oral or intravenous bolus (e.g., 80 mg) followed by intermittent high
bid or 40 mg tid) for 3 days.Then twice-daily PPI on days 4–14 followed by once-daily PPI.
Intensive PPI therapy
Intravenous bolus (80 mg) followed by infusion (8 mg/h) for 3 days; or oral or intravenous bolus (e.g., 80 mg) followed by intermittent high doses (e.g., 40–80 mg bid or 40 mg tid) for 3 days.Then twice-daily PPI on days 4–14 followed by once-daily PPI.
The promotility agent—— ~30 min before endoscopy, also may be considered to improve visualization at endoscopy: i
erythromycin, 250 mg intravenously
Discharge from the emergency room with outpatient management has been suggested for patients with a Glasgow-Blatchford score (possible range 0–23, Table 44-1) of 0–1 or 0–2 among patients <70 years
t
Multidetector CT angiography is likely superior to nuclear scintigraphy and increasingly used in its place.
t
Fecal occult blood testing is recommended only for colorectal cancer screening, beginning at age 50 in average-risk adults.
beginning at age 50
