GI Bleeding Flashcards
ligament of tretz
proximal to ligament of treitz- upper GI bleeding. distal to ligament of treitz- lower GI bleeding
ligament of treitz separates
duodenum from jejunum
UGI bleeding prognosis
self limited in 80%. remaining 20%- medical therapy and EGD
causes of acute UGI bleeding
PUD (most common), portal HTN, mallory weiss tear, vascular anomalies, gastric neoplasm, erosive gastritis, erosive esophagitis
incidence of bleeding from peptic ulcer dz is decreasing d/t
tx of h. pylori and tx with PPI’s
tx of portal hypertension
IV octrotide infusion
portal HTN causing acute UGI bleeding most often d/t
varices (esophageal, gastric, duodenal)
tears at the GE junction d/t retching
mallory-weiss tears
mallory -weiss tears most commonly occur in what type of patients?
alcoholics and bulemics
vascular anomalies causing acute UGI bleeding include
angioectasias (1-10 mm dialted submucosal vessels), telangectasias (dilated venules), and Dieulafoy’s lesions (dilated artery in proximal stomach)
angioectasias most common in
right colon
erosive gastritis causing acute UGI bleeds d/t
NSAIDS, alcohol, or severe medical or surgical illness
erosive esophagitis causing acute UGI bleeds (rare) results form
chronic GERD
Is hgb/hct helpful in determing severity in GI bleeding?
may take 1-3 days to equilibrate so do not rely on this value
management/tx of acute UGI bleed
strat with looking at VS (Hgb, BP, PP, HR,, UO, MS). if normal, check orthostatics. Get labs- CBC, PT, chem 7, LFT, type and screen. Hook up 2 large bores- IVF. type and cross 2-4 units if severe bleeding. CVP monitoring, NG tube. risk stratification to determine EGD within 2-4 hours or within 24 hours
If need to clear stomach in case of upper GI bleed
don’t do gastric lavage. use IV erythromycin to clear stomach
NG aspirate of red blood or coffee grounds=
confirms UGI source of bleeding.
Bright red blood vs. clear aspirate from NG tube
high risk of complications. if clear= duodenal source of bleeding
blood replacement in acute UGI bleeding
Hgb should raise 1 gram for each unit of PRBC’s given. In massive bleeding, give 1 unit FFP for every 5 units of PRBC’s.
when is FFP given in acute UGI bleeding
If massive bleeding or if patient with coagulopathy
when are platelets transfused in acute UGI bleeding?
if less than 50,000 or if patient has taken ASA or clopidogrel
when is DDAVP given in acute UGI bleeding
uremic patients
Hgb should be kept in range of ___ in acute UGI bleeding replacement
6-10
low risk- acute UGI bleeding
no evidence of active bleeding. admit to GMB or stepdown. EGD within 24 hours.
high risk indications and management - acute UGI bleeding
hematemesis, bright red blood per NG, shock, advanced liver disease, hypovolemia unresponsive to resuscitation. serious comorbid disease. ADMIT TO ICU, EGD WITHIN 2-4 HOURS
History is only 40% accurate, so __ used to identify source of bleeding in acute UGI bleeds
EGD
meds for acute UGI bleeding
IV “prazole” (PPI) or high dose oral PPI prior to EGD. intra-arterial embolization, TIPS, surgery
95% of LGI bleeding is from
colon
most common cause of LGI bleed
diverticulosis
most common cause of UGI bleed
peptic ulcer disease
what increases risk of diverticulosis
ASA and NSAIDS
causes of acute LGI bleeding
diverticulosis, angioectasias, neoplasms, IBD, anorectal disease, ischemic colitis, infectious colitis
most common to see those over 70 yo and in patients with renal failure (acute lower Gi bleeding cause)
angioectasias
BRBPR in patients over 50, PAINLESS
diverticulosis
most common diagnostic instruments to determine source of bleeding in UGI and LGI bleeds
EGD, colonoscopy. If massive LGI bleeding in hemodynamiccally unstable patient, do angiography
diarrhea w/intermittent hematochemize, abd pain, tenesmus, urgency of stool
IBD
bright red blood that drips into toilet after BM
anorectal disease (hemorrhoids, fissures, stercoral ulcers)
where does ischemic colitis occur
“watershed” areas of colon
Diagnosis of acute lower GI bleed
- exclude UGI source. 2 anoscopy/sigmoidoscopy. 3. colonoscopy 4. tagged RBC scan 5. angiography 6. small intestine push enteroscopy 7. capsule endoscopy
how to exclude UGI source in diagnosis of LGI bleed
if unstable patient, NG tube for aspiration. EGD performed in patients with hematochezia and hemodynamic instability
If patient presents with LGI bleeding, is younger than 45, and has small volume bleeding–>
anoscopy/sigmoidoscopy to look for anorectal dz, IBD, infectious colitis
bowel prep done in most cases for colonoscopy- this is performed within 24 hours vs. 2 hours if…
24 hours if bleeding minimal. within 2 hours of prep if bleeding severe
embolization of bleeding vessel effectively stops bleeding in 95%. but complication rate 5%-
ischemic colitis
acute lower GI bleeding diagnostic instrument used to identify lesions in small intestine
push enteroscopy
negatives of capsule endoscopy
gretaer potential for hemorrhage, hard to locazline bleeding site
tx for acute LGI bleeding
colonoscopy (cautery), angiography with embolization, surgical tx
surgical tx indications in acute LGI bleeding tx
ongoing bleeding, or if transfusion requirements are more than 6 units in 24 hours, or if 2 or more hospitalizations for diverticular hemorrhage
segmental colon resection vs. subtotal colectomy
if preoperative localization done by antiography or tagged RBC scan, then segmental colon resection. if source of LGI bleed cannot be localized, do subtotal colectomy
obscure Gi bleeding -
bleeding of unknown origin that persists or recurs after negative EGD and colonoscopy
obscure GI bleeding most commonly arises from lesions in
small intestine. (1/3 are missed lesions of stomach or colon)
etiology of Obscure GI bleeding
if over 40, NSAID induced or angioectasias. if uncer 40, SB neoplasm, crohn’s, celiac dz, meckel’s diverticulum
evaluation of younger patients and symptomatic older patients for obscure GI bleeding
EGD and colonoscopy to r/o missed lesion, capsule endoscopy if scopes are negative. add meckel’s scan if younger than 30
occult Gi bleeding is how much
less than 100 ml/day (not apparent to patient)
occult GI bleeding identified by
FOBT or iron deficiency anemia (serum ferritin less than 30-45 mcg/L
occult GI bleeding that is asymptomatic , positive FOBT
colonoscopy
occult GI bleeding that is symptomatic, positive FOBT
colonoscopy and EGD
if patient is greater than 60 without symptoms of occult GI bleeding, mange—
trial iron supplementation and observe. if no response, pursue a small bowel source
if patient greater than 60 and symptomatic or less than 60, manage…
pursue evaluation of small bowel
occult Gi bleeding- STOP
nsaids, asa, clopidogrel
