GI bleeding Flashcards
1
Q
Upper, middle, lower GI bleeds
A
- Upper: esophagus, stomach, duodenum
- Separation of upper from middle: ligament of trietz
- Middle: jejunum, ileum
- Lower: colon
2
Q
Examples of GI bleeds for each segment
A
- Upper: PUD bleeding, varices
- Middle: tumor, AVM, vascular ectasias, NSAIDs
- Lower: diverticular, tumor
3
Q
Manifestations of GI bleeds
A
- Hematemesis: either frank blood (blood in stomach for short time) or coffee-ground emesis (blood in stomach for long time)
- Melena: black stool from slow upper GI bleed, less commonly from SI or right colon
- Hematochezia: bright red blood in stool, usually due to colonic bleed or very rapid upper/middle bleed
4
Q
Approach to PUD bleeding
A
- Peptic ulcers: due to increased acid content of stomach and inflammation, from NSAIDs and/or H pylori
- NSAIDs reduce protective GI PG synthesis, resulting in reduced mucosal blood flow, increased WBC adherence, reduced bicarb production
- H pylori survives in antrum of stomach and breaks down urea in the unstirred layer to ammonia and CO2, exposing mucosa to acid
- Management of PUD bleeding: resus (airway/blood transfusion), medical Rx, endoscopic/surgical eval/Rx
- Pts w/ active bleeding or visible vessels need endoscopic Rx, w/ F/U PPI Rx
5
Q
Approach to variceal bleeding 1
A
- Portal HTN (from cirrhosis) leads to splanchnic vasodilation and thus back-up of blood thru porto-systemic collaterals
- These include esophageal varices, caput madusae (peri-umbilical), retroperitoneal, and hemorrhoidal varices
- Hepatic portal pressures >12mmHg associated w/ bleeding
- Pharmacologic Rx of portal HTN bleeding: BBs and octreotide both constrict splanchnic arteries and reduce blood in GI tract
- Octreotide generally better b/c it does not lower BP as much as BBs
6
Q
Approach to variceal bleeding 2
A
- Ablative Rx: ligation of varices in the esophagus via endoscopy reduces esophageal bleeding
- TIPS (transjugular intrahepatic portal-systemic shunt): redirects portal blood to IVC by re-routing it around liver
- Also can give antibios in setting of active variceal bleeding: prevent infection, re-bleed, lowers mortality
- Portal HTN also causes gastropathy: slow oozing of blood, no risk of brisk bleed (more difficult to Rx than esophageal varices)
- Rx w/ BBs/TIPS
7
Q
Methods to evaluate and causes of middle GI (SI) bleed
A
- SI bleeds were majority of obscure bleeds previously
- Capsule endoscopy
- Double balloon enteroscopy
- Vascular ectasias major cause of SI bleeding: friable thin walled vessel often w/ A-V connections
- Vascular ecstasias associated w/ renal disease and age
- Vascular ecstasies can be ablated by endoscopic coagulation
8
Q
Lower GI bleeding
A
- Diverticular bleeding and vascular ecstasies are most common
- Should also consider brisk upper GI bleed
- Ischemia, radiation, infection and inflammatory processes generally low bleeds and associated w/ other Sx
- Therapeutic colonoscopy is a consideration but controversial
- Non-emergent colonoscopy should be done (after bleeding stops) to confirm Dx