GI Bleeding

Question 1

physiologic response to acute blood loss

Answer 1

*pressure = flow x resistance
*acute blood loss results in DECREASED FLOW:
-compensatory tachycardia
-peripheral vasoconstriction (cold, clammy skin)
-orthostatic hypotension (>25-30% blood loss)
-signs of shock (>50% blood loss)
*oliguria

Question 2

hematemesis

Answer 2

red blood in emesis (vomit)

Question 3

hematochezia

Answer 3

red blood in stool

Question 4

melena

Answer 4

*black, tar-like stools
*takes 50 ml or more of blood in the stomach to turn stools black

Question 5

“coffee-grounds”

Answer 5

black/brown flecks in stool or emesis (partially digested blood)

Question 6

overt GI bleeding

Answer 6

you can see blood with your eye (red or black)

Question 7

occult GI bleeding

Answer 7

no visible blood in emesis, NG aspirate, or stool

Question 8

obscure GI bleeding

Answer 8

the source of bleeding is unknown (traditionally used after EGD/colonoscopy have been done and were unrevealing)

Question 9

signs/symptoms of upper GI bleeding

Answer 9

*hematemesis
*coffee-ground emesis
*melena
*bloody NG aspirate
*BUN/Cr > 20:1
*drop in Hgb, iron deficiency
*caveat: hematochezia & hypotension if brisk upper

note - upper GI bleeding = source proximal to ligament of Treitz

Question 10

signs/symptoms of lower GI bleeding

Answer 10

*hematochezia (blood clots suggestive of LGIB source)
*drop in Hgb, iron deficiency
*UGIB excluded
*caveat: melena may be from right colon in slow transit

note - lower GI bleeding = source distal to ligament of Treitz

Question 11

basic principles of resuscitation of patients presenting with GI bleeding

Answer 11

*O2 per nasal cannula
*2 large bore (16G) IVs with NS wide open
*stat labs: CBC, INR, CMP, type/cross
*consider placing an NG tube
*is the patient in the right location?
*does the patient need an urgent EGD?
*does the patient need an Interventional Radiology or Surgical consultation?

Question 12

ddx of upper GI bleeding

Answer 12

*duodenal/gastric ulcers
*varices
*esophagitis
*gastric erosions
*duodenitis
*Mallory-Weiss
*tumors

Question 13

how quickly to perform EGD in GI bleeding

Answer 13

*within 12 hours for:
-suspected variceal hemorrhage
-bleeding unresponsive to resuscitation

*within 24 hours for most others

Question 14

what can we do with GI endoscopy to stop upper GI bleeding?

Answer 14

*mechanical hemostasis (through or over the scope clips)
*coagulation
*vasoactive injections
*hemostatis spray
*banding

Question 15

medical management of upper GI bleeding

Answer 15

1. resuscitation/stabilization (includes PPI)
2. EGD with possible treatment
3. reevaluate adjuvant therapies
4. monitor for recurrent bleeding
5. observe in hospital for 72 hours after endoscopic therapy
6. future repeat EGD?

Question 16

ddx of lower GI bleeding

Answer 16

*colonic sources (95%)
-diverticular hemorrhage!!!! (most common)
-anorectal
-neoplasia
-post-polypectomy
-IBD
-infectious colitis

*small bowel sources (5%)
-angioectasia
-Crohn’s disease
-infectious enteritis
-neoplasia