GI Bleeding

Question 1

DDx for Upper GI Bleed

Answer 1

“HEAPED GM”

Hemobilia
Esophagitis
Aortoduodenal fistula
PUD
Esophageal varices
Dieulafoy lesion
Gastritis
Mallory weiss

Question 2

3 most common types of upper GI bleeding

Answer 2

1. PUD 45%
2. Gastritis - 25%
3. Esophageal varices - 10%
4. Mallory-Weiss tear 7%
5. Esophagitis/duodenitis 6%

Question 3

DDx for Lower GI Bleed

Answer 3

"ADVISED CH"
Anal fissure, angiodysplasia
Diverticulosis
Vascular ectasia, Volvulus
Ischemic colitis, Infection, radiation
Small intestine tumors
Empty
Diverticulum
Colorectal cancer
Hemorrhoids

Question 4

Hematemasis

Answer 4

Vomiting blood - source is proximal to ligament of treitz

Question 5

Coffee ground emesis

Answer 5

Upper GI

Question 6

Hematochezia

Answer 6

Bright red blood per rectum (BRBPR). May be seen in cases of vigorous upper GI bleeding

Question 7

Blood coating stool or dripping into toilet

Answer 7

Anorectal source

Question 8

Initial management of GI Bleed

Answer 8

2 large bore IVs
Isotonic fluid LR
Monitor vitals, foley, CVP
Transfuse pRBC if large
NG Lavage

Question 9

Labs obtained for suspected upper GI Bleed

Workup

Answer 9

CBC
Electrolytes
LFTs
PT/PTT
Type and cross
4-6 units of pRBC

NG lavage; stool guaic
Imaging: Upright AXR; upper endoscopy

Question 10

Melena

Answer 10

Black, tarry stools, usually due to an upper GI bleeding source

Question 11

Signs and symptoms of GI Bleeding

Answer 11

Hematemesis
Melena
Hematochezia
Dehydration - pallor, tachycardia, orthostasis, syncope, shock, epigastric discomfort

Question 12

Treatment for Upper GI Bleed

Answer 12

Assess fluid status and resuscitate with 2 L LR
2 large bore IVs 16-18 gauge
Assess magnitude of hemorrhage - vitals UOP, serial Hgb, O2 sat
Correct coagulopathy with FFP/vitamin K

ID the bleeding source:
NG lavage
EGD: coagulate bleeding vessels, biopsy any ulcers or masses, test for H. pylori
Angiography - Rate of bleeding >0.5 cc/min

Question 13

How many upper GI bleeds require surgery?

Answer 13

80-85% will stop spontaneously, 20% require surgery

Question 14

Indications for surgical treatment of Upper GI Bleed

Answer 14

• 6 or more units of blood in first 24 hours or if rebleed while receiving maximal medical therapy
• Esophageal variceal bleeding despite medical measures - consider TIPS
• Perforation
• Gastric outlet obstruction

Question 15

How can you control upper GI Bleeds?

Answer 15

Sclerotherapy or embolization
Vasopressin + Nitro (to decrease risk of MI)
Balloon tamponade <48 hours

Question 16

Signs and symptoms of lower GI bleed

Answer 16

BRBPR or melena, abdominal pain, anorexia, fatigue, syncope, change in bowel habits

Question 17

Treatment for LGIB

Answer 17

Resuscitate
ID bleeding source: NG lavage bilious GI contents, DRE, anoscopy
Colonoscopy
RBC Scintigraphy
Angiography
Control bleeding - Embolization or laser coagulation
Surgery

Question 18

Surgical indications for lower GI Bleed

Answer 18

Persistent bleeding despite angiographic or endoscopic therapy
Segmental colectomy if bleeding site is well localized.

Question 19

2 most common causes of LGI bleed

Answer 19

Diverticulosis

Vascular ectasia