GI Bleed Lecture

Question 1

in what percentage of GI bleeds is there not a known cause?

Answer 1

10-15 percent

Question 2

if your patient with a GI bleed presents with severe belly pain and involuntary guarding and/or rebound tenderness, what should be on top of your differential?

Answer 2

perforation

Question 3

frank, bright red blood in the vomit is known as what? what does it usually mean?

Answer 3

hematemesis

active vigorous bleed

Question 4

coffee ground appearing vomit would present in what type of bleed?

Answer 4

a slower, more limited bleed

Question 5

true or false – black tarry stool (melena) indicates an upper GI bleed

Answer 5

false

it is NON-specific

Question 6

hematochezia (bright red blood in the stool) usually indicates a lower GI bleed. what is the exception?

Answer 6

when accompanied by hypotension, it indicates a MASSIVE upper GI bleed

Question 7

how much total volume loss usually causes supine hypotension?

Answer 7

40 percent total volume loss

Question 8

how much total volume loss usually causes orthostatic hypotension?

Answer 8

15 percent total volume loss

Question 9

how much blood is in a typical male’s human body? how about a female?

Answer 9

male = 5.6 L
female = 4.5 L

Question 10

what is the maximum survivable blood loss?

Answer 10

estimated 40 percent total volume loss

Question 11

in the face of a GI bleed, you should order an _____ every 4-6 hours

Answer 11

hemoglobin and hematocrit

Question 12

what on labs will differentiate between an upper GI bleed and a lower GI bleed?

Answer 12

upper GI = BUN:Creatinine ratio 20:1

lower GI not that?

Question 13

does every patient with a GI bleed get a coagulation panel? how about a type and cross?

Answer 13

YES. everyone

Question 14

how do we manage a non-urgent GI bleed? (4)

Answer 14

1) GI consult
2) IV PPI
3) MAYBE transfuse
4) get upper EGD today or sometime tomorrow

Question 15

what is considered a GI bleed emergency?

Answer 15

hypotension (of any kind) + frank blood (witnessed or reported)

Question 16

loaded question, but how do we manage an emergent GI bleed?

Answer 16

1) cardiac monitoring; frequent BP checks
2) establish 2 large bore IV sites
3) bolus IVF: at least 500cc NS
4) supplemental O2
5) IV PPI
6) prepare to transfuse

Question 17

who do we always consult with when managing an emergent GI bleed? (3)

Answer 17

GI for urgent endoscopy
general surgery
intensivist

Question 18

if a variceal bleed is high on your differential, how should you treat?

Answer 18

1) octreotide
2) get endoscopy
3) consider TIPS (transjugular intrahepatic protosystemic shunt) procedure

Question 19

if patient’s bleed is a result of being overly anti-coagulated on coumadin, how do you treat?

Answer 19

1) stop the medication

2) vitamin K IV + Kcentra (prothrombic complex concentrate)

Question 20

how large of a drop in hemoglobin or hematocrit is considered worrisome in the face of a GI bleed?

Answer 20

1 gram drop considered significant

caution: hemodilution can throw you off! correlate with symptoms

Question 21

if patient is experiencing a GI bleed on one of the novel direct oral anticoagulants, what should you do?

Answer 21

consult the pharm D – this stuff is new and always changing

Question 22

are lower GI bleeds considered more or less severe than upper GI bleeds? how do we manage them?

Answer 22

lower typically less severe

• manage same way as upper MINUS the PPI
• first r/o upper bleed and then get COLONOSCOPY once patient is stable and no longer bleeding. can be done outpatient