GI Bleeding

Question 1

GI bleeding 2 types

Answer 1

1. Overt (visible bleeding)
2. Occult (no exteriorization of blood, but person is slowly becoming anemic)

Question 2

Epidemiology: 4 most common types/causes of GI bleeding

Answer 2

1. Upper GI bleeding (60.6)
2. Lower GI bleeding (35.7)
3. Peptic ulcer bleeding (32.1)
4. Colonic diverticular bleeding (23.9)

Question 3

3 types of overt GI bleeding

Answer 3

Upper
Obscure (middle - most rare)
Lower

Know how to define these in terms of GI regions!

Question 4

Upper GI bleeding - symptoms

Answer 4

• Hematemesis (vomiting of blood or coffee-ground material)
• Melena (black, tarry stool)
• Hypovolemic shock (+/-)

Question 5

3 main causes of severe upper GI bleeding

Answer 5

1. gastric or duodenal ulcer
2. gastric or esophageal varices (rupture)
3. erosive esophagitis (due to reflux, drugs, toxins)

Question 6

Upper GI bleeding: Initial Management

Answer 6

1. ABCs (IV, intubation, INR correction)
2. Type and cross-match (figure out what blood type the patient has and make sure transfusion blood is ready if needed)
3. Fluid resuscitation
4. Risk stratification (clinical or endoscopic)

Question 7

How can the nitrogen and creatinine level help us diagnose upper GI bleeding

Answer 7

?

Question 8

Patients with upper GI bleeding should undergo … within 12-24 hours.

Answer 8

endoscopic evaluation

Question 9

Why is endoscopic evaluation so important for patients with upper GI bleeding

Answer 9

It identifies the site of bleeding with a sensitivity of 92% and a specificity near 100% while also providing hemostasis, if needed.

Question 10

What is the goal of endoscopic therapy for UGIB? (2)

Answer 10

To stop acute bleeding and reduce the risk of recurrent bleeding.

Question 11

Endoscopic therapy (UGIB) is reserved for…

Answer 11

lesions that have a high risk stigmata

Question 12

What are some of the available endoscopic treatments (4)

Answer 12

Injection
Thermal coagulation
Mechanical compression (clips)
Hemostatic powders

Briefly understand how these work

Question 13

Describe the medical therapy for (non-variceal) UGIB (i.e. medications)

Answer 13

Proton Pump Inhibitors:
- Result in profound acid suppression
- Promote platelet aggregation
- Promote and stabilize clot formation

Question 14

Why are PPIs such a good therapy for UGIB?

Answer 14

They reduce re-bleeding and surgery rates; in patients with high-risk stigmata post endoscopic therapy reduce mortality.

Question 15

For patients with high risk - dose

Answer 15

High-dose IV PPI over 72 hours

Question 16

UGIB prognosis depends on…

Answer 16

the cause of bleeding

Question 17

Compare the chances of re-bleeding if the UGIB cause is non-variceal vs variceal

Answer 17

Non-variceal: 9%
Variceal: 60%

Question 18

Compare the mortality risk if the UGIB cause is non-variceal vs variceal

Answer 18

Non-variceal: 2%
Variceal: 33%

Question 19

Understand variceal bleeding

Answer 19

• Due to portal hypertension from liver cirrhosis
• Shunting of blood through submucosal veins
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Question 20

How is variceal UGIB treated?

Answer 20

Combination of pharmacotherapy and endoscopy.

Pharmacotherapy:
* octreotide
* somatostatin
* endoscopy

Endoscopy:
* band ligation, sclerotherapy

Also if needed: radiological therapy (prosthetic shunting)

Question 21

What may suggest lower GI bleeding on history? (3)

Answer 21

History of diverticulosis, abdominal cramping followed by bloody diarrhea, recent polypectomy.

Question 22

Lower GI bleeding: Initial Management

Answer 22

1. Resuscitation (same as UGIB)
2. Endoscopic evaluation
3. Flexible sigmoidoscopy/anoscopy
4. Colonoscopy

Question 23

What is the purpose of a colonoscopy in LGIB management?

Answer 23

Allows for diagnosis
May help with hemostasis of amenable lesions

Question 24

In what case is colonoscopy not useful (LGI)

Answer 24

Acute setting (severe bleeding - you won’t even see anything)

Question 25

Most common causes of lower Gi bleeding (5)

Answer 25

1. Diverticulosis
2. Internal hemorrhoids
3. Ischemic colitis
4. Rectal ulcers
5. Colonic vascular lesions

Question 26

LGIB: Therapy

Answer 26

If hemodynamically unstable, consider upper endoscopy once stabilized.

Urgent colonoscopy is no better than elective colonoscopy for improving outcomes

Question 27

Upper GI bleeding tends to be more serious & life-threatening

Most LGIB (diverticular cases) stop on their own

Question 28

Most patients with obscure GI bleeding patients have bleeding from…

Answer 28

the small intestine (that is beyond the reach of an upper endoscope or colonoscope)

Question 29

Most common cause of small intestinal bleeding

Answer 29

Vascular lesions (angiectasis) - abnormal venous malformations (get too close to the surface)

Question 30

Other than vascular lesions, 2 other causes of small intestinal bleeding

Answer 30

Ulcers
Tumours

Question 31

Overt obscure
Occult obscure

Question 32

What is another name for enteroscopy?

Answer 32

videocapsule endoscopy

Question 33

Obscure does not mean it is coming from the small bowel! It can also means it was missed on upper endoscopy or colonoscopy

Question 34

What is an important consequence of both overt or occult blood loss?

Answer 34

Iron deficiency

Question 35

Is iron deficiency frequently caused by GI bleeding?

Answer 35

No, a lot of the time it is caused by…
* iron deficiency
* iron malabsorption
* chronic red blood cell destruction (hemolysis)