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

1. Upper (esophagus, stomach, upper duodenum)
2. Obscure/Middle (small intestine)
3. Lower (large intestine, rectum)

Know how to define these in terms of GI regions!

Question 4

Upper GI bleeding - Symptoms (3)

Answer 4

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

Question 5

What percentage of patients who present with hematochezia (passage or RBCs or clots per rectum) have an upper GI source of bleeding?

Answer 5

15-20%

Question 6

3 main causes of severe upper GI bleeding

Answer 6

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

Question 7

Upper GI bleeding: Initial Management (4 steps)

Answer 7

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 8

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

Answer 8

In upper GI bleeding, the blood urea nitrogen level typically increases to a greater extent than the creatinine level.

Question 9

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

Answer 9

endoscopic evaluation

Question 10

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

Answer 10

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

Question 11

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

Answer 11

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

Question 12

Endoscopic therapy (UGIB) is reserved for…

Answer 12

lesions that have a high risk stigmata

Question 13

What are some of the available endoscopic treatments (4)

Answer 13

Injection
Thermal coagulation
Mechanical compression (clips)
Hemostatic powders

Briefly understand how these work

Question 14

Briefly describe the following endoscopic treatments:

Injection
Thermal coagulation
Mechanical compression
Hemostatic powders

Answer 14

Injection: Epinephrine is injected to the site of injury to induce vasoconstriction

Thermal coagulation: A probe applies heat to coagulate the bleeding vessel

Mechanical compression: Hemostatic clips are placed on the bleeding vessel to stop the bleeding.

Hemostatic powders: Are sprayed on the site of bleeding to promote clot formation

Question 15

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

Answer 15

Proton Pump Inhibitors:
Result in profound acid suppression that promotes platelet aggregation and clot formation

Question 16

Why are PPIs such a good therapy for UGIB?

Answer 16

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

Question 17

For patients with high-risk stigmata post endoscopic therapy - What is the PPI dose?

Answer 17

High-dose IV PPI over 72 hours (reduces mortality)

Question 18

UGIB prognosis depends on…

Answer 18

the cause of bleeding

Question 19

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

Answer 19

Non-variceal: 9%
Variceal: 60%

Question 20

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

Answer 20

Non-variceal: 2%
Variceal: 33%

Question 21

Explain variceal bleeding in the esophagus (UGIB)

Answer 21

Variceal bleeding happens because of high pressure in the portal vein (portal hypertension), usually due to liver cirrhosis. This forces blood to reroute (shunt) through small veins in the lower esophagus, causing them to swell and form varices. These swollen veins have thin walls and can easily break, leading to severe bleeding into the esophagus.

Question 22

How is variceal UGIB treated?

Answer 22

Combination of pharmacotherapy and endoscopy.

Pharmacotherapy:
* octreotide
* somatostatin
* antibiotics

Endoscopy:
* band ligation, sclerotherapy

Also if needed: radiological therapy (prosthetic shunting)

Question 23

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

Answer 23

• History of diverticulosis
• Abdominal cramping followed by bloody diarrhea
• Recent polypectomy.

Question 24

Lower GI bleeding: Initial Management

Answer 24

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

Question 25

What is the purpose of a colonoscopy in LGIB management? (2)

Answer 25

Allows for diagnosis May help with hemostasis of amenable lesions

Question 26

In what case is colonoscopy not useful (LGI)

Answer 26

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

Question 27

Most common causes of lower Gi bleeding (5)

Answer 27

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

Question 28

Briefly define diverticulosis

Answer 28

Diverticulitis occurs when small bulging pockets form on the inner wall of the colon. They may rupture and bleed.

Question 29

LGIB: Therapy Hemodynamically unstable Hemodynamically stable Severe/persistent bleeding

Answer 29

If hemodynamically unstable: 1. Stabilize the patient (resuscitation, ABCs) 2. Consider upper endoscopy once stabilized (to rule out upper GI source of bleeding) Hemodynamically stable: Elective colonoscopy (urgent colonoscopy does not improve outcomes) Severe/Persistent bleeding: Perform radiologically guided percutaneous embolization

Question 30

What is the risk of angiographic embolization or infusion of vasoconstrictors when treating LGIB?

Answer 30

10% risk of causing local ischemia (but success rate is 80%)

Question 31

Is surgical management of LGIB often required?

Answer 31

No, because most LGIB is self-limited or easily managed with medical or endoscopic therapy (LGIB is less dangerous than UGIB).

Question 32

Surgical treatment of LGIB is reserved for... (2)

Answer 32

1. Patients with malignat lesions 2. Patients with recurrent or persistent ischemic colitis or diverticulosis

Question 33

What is the prognosis for LGIB? What does it depend on?

Answer 33

Overall mortality rate is low (2-4%). The outcome depends on the cause of bleeding (but is favourable in most cases).

Question 34

Where is the source of bleeding in patients with obscure (middle) GI bleeding?

Answer 34

The small intestine or any region that is beyond the reach of an upper endoscope or colonoscope.

Question 35

We consider obscure GI bleeding to be present if...

Answer 35

bleeding is persistent and recurrent despite a negative initial GI evaluation (including upper endoscopy and colonoscopy).

Question 36

Since the small intestine cannot be accessed by endoscopy nor colonoscopy, how can we examine for obscure bleeding?

Answer 36

Videocapsule endoscopy (enteroscopy): a non-invasive procedure that uses a small, pill-sized camera that the patient swallows

Question 37

Most common cause of small intestinal bleeding (obscure GIB)

Answer 37

Vascular lesions (angiectasias) *Abnormal, dilated blood vessels in the GI that can cause chronic or intermittent bleeding*

Question 38

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

Answer 38

Ulcers Tumours

Question 39

Name 2 types of lesions that cause obscure GI bleeding and are within reach of standard endoscopes but are not recognized as the bleeding site.

Answer 39

Cameron's ulcers Internal hemorrhoids

Question 40

Name an intermittently bleeding lesion considered a source of obscure Gi bleeding

Answer 40

Dieulafoy's lesion

Question 41

What is another name for enteroscopy?

Answer 41

videocapsule endoscopy

Question 42

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

Answer 42

Iron deficiency

Question 43

Is iron deficiency frequently caused by GI bleeding?

Answer 43

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