GI Bleeding Flashcards
Clinical Presentation
Initial evaluation & resuscitation
Assess what? Use what?
Access required?
Lab to obtain for resuscitation?
Monitor what labs?
Transfuse when?
Supplement what electrolyte? why?
Assess severity of bleeding; continuous monitoring of HD parameters to guide resuscitation
2 large bore IVs immediately
Type & Cross
CBC, Coags, Ca+
Ca+; citrate in blood products binds with Ca+ leading to hypocalcemia
Estimating Blood Loss
Class I
Loss of how much total blood volume?
Clinical findings include?
</= 15%
may be minimal or absent d/t compensation of transcapillary refill
Estimating Blood Loss
Class II
Loss of how much total blood volume?
S/Sx?
Compensatory mechanism activated?
May see drop in what due to what?
15-30%
orthostatic changes in HR, BP
vasoconstriction maintains flow to vital organs
UOP; Splanchnic flow
Estimating Blood Loss
Class III
Loss of how much total blood volume?
Onset of what?
S/Sx?
30-40%
decompensated hypovolemic shock
hypotension, decreased UOP
Estimating Blood Loss
Class IV
Loss of how much total blood volume?
S/Sx?
Changes may be what?
> 40%
hypotension & oliguria more profound (UOP < 5ml/hr)
irreversible
Resuscitation of hypovolemic shock goal
maintain DO2 to tissues & sustain aerobic metabolism
Support CO
Correct Hgb deficits
How much IV crystalloid infusion to replace blood loss?
What type to use?
What type of blood to use during resuscitation?
3ml/1ml blood loss
LR 1-2L initially
NS (be aware of possible hyperchloremic acidosis)
O-
Transfuse for hgb < what?
Transfuse for Hgb < what for cardiac or ortho surgery?
7
8
Hx and Risk Factors for GI Bleeding
elderly?
Younger?
other risk factors?
Diverticulosis, vascular ectasia, ischemic colitis
Varices, ulcers, esophagitis
previous bleeding/GI dz, previous surgery, underlying dz
Meds that can cause GI bleeding
NSAIDs
ASA
Clinical Findings for GI bleeding
Change in bowel habits
Weight loss
Abdominal pain
Hematemesis
Coffee-ground emesis
Bloody NG aspirate
Melena
Hematochezia
Upper GI bleeding is from where?
Endoscopy recommended within what time frame?
esophagus, stomach, duodenum
24 hrs
Differential Dx for Upper GI bleeding
Nonvariceal
peptic ulcer
Mallory-Weiss tear
Erosive esophagitis or duodenitis
esophagitis
dieulafoy’s lesion
angiodysplasia
malignancy
Differential Dx for Upper GI bleeding
Variceal
esophageal
gastric
Clinical Manifestations of Peptic Ulcer Dz
Recurrent pain with periods of remission described how?
usually epigastric
may radiate to back
burning
painful hunger
may be relieved by, worsened by, or unrelated to food
nocturnal pain several hrs after late meal c/w ulceration
Clinical Manifestations of Peptic Ulcer Dz
heartburn/acid reflux into throat c/w GERD
N/V may be present
Complications of PUD
Bleeding, perforation
When to test for H. Pylori?
Active PUD
Mucosa associated lymphoid tissue (MALT)
H/o endoscopic resxn of early gastric CA
Uninvestigated dyspepsia if < 60 (without alarm features)
Chronic NSAIDs
Unexplained iron deficiency anemia
ITP
/
Alarm features for H. Pylori?
bleeding
anemia
early satiety
unexplained weight loss
progressive dysphagia
recurrent vomiting
family h/o GI CA
\
Mallory-Weiss tears are what?
mucosal & possibly submucosal lacerations from sudden increase in pressure in cardia & lower esophagus from vomiting
Mallory-Weiss tears
how to stop bleeding?
tears are usually how long and where?
usually ceases spontaneously
1.5-2 cm; @ GE junction or proximal stomach
Dieulafoy’s lesions
what are they?
Where are they typically located?
visible vessel protruding from small mucosal defect no ulceration
in lesser curvature
Benign GI Neoplasms
GISTs
Carcinoid
lipomas
Malignant GI Neoplasms
adenoca of esophagus
stomach
duodenum
SCCA of esophagus
gastric or duodenal lymphomas
H. Pylori Treatment
Is there a PCN allergy? N
Previous Macrolide exposure for any reason? N
What is the recommended treatment?
Bismuth quadruple
CONCOMITANT
Clarithromycin triple with amoxicillin
H. Pylori Treatment
Is there a PCN allergy? N
Previous Macrolide exposure for any reason? Y
What is the recommended treatment?
Bismuth quadruple
Levofloxacin triple
Levofloxacin sequential
H. Pylori Treatment
Is there a PCN allergy? Y
Previous Macrolide exposure for any reason? N
What is the recommended treatment?
Clarithromycin triple with metronidazole
Bismuth quadruple
H. Pylori Treatment
Is there a PCN allergy? Y
Previous Macrolide exposure for any reason? Y
What is the recommended treatment?
Bismuth quadruple
Hx found in varices
Symptoms of liver dz
family h/o hereditary liver dz (Wilson Dz)
Lifestyle (ETOH, drugs)
PMH - jaundice, prior blood transfusions
Exam for varicies
signs of bleeding
dyspnea
jaundice
telangiectasia
palmar erhythema if cirrhosis
ascites
distended abd wall veins
Risk factors for Stress-Related Mucosal Dz
recent major surgery
major trauma
severe burns
TBI
MSOF
MV>48hrs
coagulopathy (plt ct < 50, INR > 1.5, PTT > 2x NL)
/
GI prophylaxis
Level I recs All patients with?
Level II recs ICU patients with what?
Level III recs Injury severity score > what? and what med?
MV, coagulopathy, TBI, major burn
multi-trauma, sepsis, acute renal failure
15; high dose steroids (>250mg hydrocortisone/day)
GI Prophylaxis preferred agents
Level I recs: no difference b/t what meds? shouldn’t use what?
Level II recs: what meds shouldn’t be used in dialysis patients?
Level III recs: what alone may be insufficient prophylaxis?
H2RAs, cytoprotectives & PPI; Antacids
aluminum containing meds
enteral nutrtion
GI prophylaxis Duration of therapy
Level I?
Level II?
Level III?
none
duration of MV or ICU stay
until able to tolerate enteral nutrition
Treatment for Stress-Related Mucosal DZ Upper GI bleed?
Endoscopy as in PUD
Surgery for those with uncontrolled hemorrhage; usually vagotomy, oversew, or subtotal/total gastrectomy (rare)
Lower GI Bleeding from where?
from source distal to ligament of Treitz
Risk factors for Lower GI bleeding?
Antiplatelets
NSAIDs
P2Y12 inhibitors
Diverticular Dz
most common cause of lower GI bleed with up to what % of cases?
More often in who? affecting up to 2/3 of those > what?
~3-15% of those with diverticulosis experience what?
patients experience painless what?
Usually ceases how? but can recur in up to what % of cases?
40%
elderly; 80 yrs
bleeding
hematochezia
40%
Ischemic Colitis/other Colitis
responsible for what % of LGIBs?
sudden decrease in what?
typical areas of involvement include what areas?
Patients experience what symptoms?
usually resolves how?
Common cause of LGIB in ICU d/t what?
On endoscopy usually appears as what?
severe bleeding from infectious colitis, XRT colitis, and inflammatory bowel dz is what?
19%
mesenteric flow; transient and reversible
watershed areas: splenic flexure, rectosigmoid junction, R colon
sudden abd pain, hematochezia w/n 24 hrs
spontaneously w/ support, rarely requires surgery
hemorrhagic nodules, cyanotic or necrotic mucosa with heomrrhagic ulcerations, or abrupt transition b/t injured & normal mucosa
rare
Angiodysplasia
Rates of occurrence as source of LGIB vary widely up to what %?
Primarily in what population?
bleeding usually has what characteristics?
On endoscopy lesions are what?
37%
elderly
brisk, painless, difficult to distinguish from diverticular bleed
flat & red with vessels extending from central feeding vessel, usually R colon
Small bowel sources of LGIBs
angiodysplasia
lymphoma
SB ulcers
Crohn’s dz
Other sources of LGIBs
Hemorrhoids
CA
Post polypectomy
Ulcers
XRT
Diagnostic Evaluations include?
Colonoscopy
CT angio
Surgery
Anticoagulation Guidance in GI Bleed
DC NSAIDs (in diverticular bleed)
DC ASA if used for primary CV prevention (Diverticular bleed)
Continue ASA if prior CV dz (diverticular bleed)
resume anticoagulants after cessation of bleeding
