GI bleeding Flashcards
_______ is the most common emergency of the GI tract
GI bleeding
Mortality from GI bleed is affected strongly by the patient’s _____ factors
comorbid
What should be the first step in the approach to a patient with a GI bleed
assess and stabilize hemodynamic status
Melena is strongly suggestive of _______ bleeding
upper
rarely right colon
Hematemesis is strongly suggestive of _____ bleeding
upper GI
Hematochezia is suggestive of ______ bleeding
lower GI
very brisk upper GI
What is the purpose of NG lavage?
assess for upper GI bleed
+ for blood- definitely an upper GI bleed
- for blood- cannot definitively rule out upper GI bleed
There is evidence to support earlier transfusion of blood in _______ patients with a GI bleed
elderly
coronary artery diseaes
______ is used to reverse blood thinning agents like warfarin and normalize the PT/INR more rapidly than Vitamin K
FFP
How do you interpret a finding of increased frequency of stools in a patient with suspected GI beed
increased frequency= more active bleeding
blood is cathartic
Chronic ______ increases risk for gastritis, gastric ulcers, duodenal ulcers
NSAID
If H&P of a patient with suspected GI bleed reveals underlying liver disease, there is increased concern for _______
variceal bleeding, portal hypertension
In patients with a history of AAA repair, there is increased concern for ______
aortoenteric fistula
Elevated _______ ratio may indicate an upper GI source of bleeding. Why?
BUN:Cr
BUN rises due to the breakdown of blood proteins to urea by intestinal bacteria which is then absorbed
_______ may not accurately reflect blood loss if measured acutely after onset of bleeding
hgb/hct
Iron deficiency anemia may indicate:
chronic GI bleed
Upper GI bleed is defined as proximal to the:
ligament of Trietz
List adverse clinical prognostic factors for GI bleeds
shock varices or cancer as cause of bleeding comorbid disease older age onset in hospital recurrent bleeding
List adverse endoscopic prognostic factors
active bleeding
bleeding from varices
visible vessel
large ulcer
The more units of blood that must be transfused, the greater the _____
mortality
The _______ travels right behind the duodenal bulb, so an ulcer in the duodenal bulb can erode and cause major bleeding
gastroduodenal artery
What is a Mallory-Weiss tear?
tear and GEJ
What is the classic presentation of a Mallory-Weiss tear?
history of recurrent retching prior to development of hematemesis
Most Mallory- Weiss tears occur on the _____ side
gastric
Describe course and treatment of Mallory-Weiss tears
- bleeding usually stops spontaneously
- treat with hemoclips, injection of epinephrine, observation
In _______, irritation of the squamous epithelium leads to erosion and ulceration
esophagitis
List causes of esophagitis
reflux
radiation
Candida, CMV
pills/ meds
What is treatment for GI bleeds due to esophagitis?
acid suppression
stop offending medications
treat infection
How does esophageal cancer cause bleeding?
bleeding can occur from primary as well as metastatic malignancies which ulcerate
In esophageal cancer there is often a history of _______ before bleeding occurs
dysphagia to solids
What is treatment for bleeds in esophageal cancer?
surgical
epinephrine
hemoclips
_________ can cause life threatening bleeding
esophageal varices
distended veins beneath the esophageal mucosa that result from increased portal pressure due to cirrhosis or portal vein thrombosis
How is active bleeding from esophageal varices treated?
band ligation
sclerotherapy
octreotide
What temporary procedure can be done for active bleeding from esophageal varices that have not been controlled by band ligation or slcerosants, until more definitive therapy can be performed?
Sengstaken blakemore tube
definitive therapy is TIPS
List possible etiologies of gastric ulcers
NSAIDs
H pylori
malignancy
List treatments of gastric ulcers
hemoclips thermal-coaptiv therapy bicap cautery epinephrine injection acid suppression
In cases of gastric ulcers, you should get biopsies to assess for ______ and test for and treat ______
malignancy
H pylori
List the stigmata of bleeding for gastric ulcers in order of most likely to rebleed
active bleeding non bleeding visible vessel clot dot clean base
_______ can reduce rebleeding, surgery, and death in patients with stigmata of bleeding in gastric ulcers
omeprazole
PPIs are good but not H2 blockers
_______ is often caused by alcohol, NSAIDs, or H pylori and bleeding is usually minor
gastritis
Define portal gastrophathy
vascular congestion of the stomach lining from increased portal pressure
- bleeding can be chronic as well as acute
What is a Dieulafoy’s vessel?
abnormally large submucosal artery that can rupture and bleed, surrounded by normal mucosa
- moderate to severe bleed
- majority occur in the stomach
What is treatment for a Dieulafoy’s vessel?
hemoclips, epinephrine injection, surgery, angioembolization
What is duodenitis?
irritation of the duodenal mucosa, most often due to NSAIDs, but can also be caused by bile acids
- mostly chronic bleeding, but can be acute
How is duodenitis treated?
Eradicate H pylori
stop NSAIDs
cholestyramine for bile acids
What are common causes of duodenal ulcers?
NSAIDs, H pylori
How are duodenal ulcers treated?
Hemoclip, cautery, epinephrine injection, surgery
What is a serious complication of duodenal ulcers?
erosion into gastroduodenal artery
What is an aortoenteric fistula?
communication between the aorta and the GI tract
- 75% occur in the third portion of the duodenum
- usually develop after AAA graft repair
_______ are angioectasias that can occur anywhere in the GI tract but are most common in the small intestine
arteriovenous malformations
What are AVMs associated with?
chronic renal failure
aortic stenosis
radiation
can be acute or chronic bleeding
What is treatment for AVMs
argon plasma coagulation
What steps are important to prevent recurrence of upper GI bleeding
eradicate H pylori
acid suppression
avoid NSAIDs
surgery- Billroth I or II
Lower GI bleeding often presents with _______
hematochezia
What is diverticulosis?
small pouches in the colon that bulge outward at weak spots in the colon wall, can bleed
What is the normal course of bleeding with diverticulosis?
spontaneously stops in 75% of people
How is diverticulosis localized?
tagged RBC scan
How is diverticulosis treated?
endoscopy is difficult, use epi and hemoclips, angiography with embolization
surgery- hemicolectomy
______ usually presents with bloody diarrhea and can have a variety of underlying causes
colitis
List causes of colitis
Crohn’s, ulcerative
infectious, C diff
Ischemic
How is bleeding due to colitis treated?
treat underlying cause
AVMs can be found in the colon and are treated with _______
argon plasma coagulation
stop anticoagulation
List signs and symptoms of colon cancer
occult GI bleed or hematochezia iron deficiency anemia abdominal pain or masses weight loss change in caliber of stool
What is a common history at presentation with hemorrhoids?
recent constipation with straining and then passage of brown stool with bright red blood
What is treatment for hemorrhoids?
observation, stool softeners, banding if repeat bleeding
What is evidence for occult bleeding?
iron deficiency anemia and/or recurrent guaiac positive
The focus of the workup for occult bleeding is detection of _______
colorectal cancer
What is the most common cause of obscure bleeding?
AVMs/ angioectasias
What techniques can be used to evaluate the small intestine in the workup of obscure/ occult bleeding?
Push Enteroscopy: using a enteroscope for an upper endoscope and pushing as far as possible into the small intestine
- Double balloon enteroscopy
- capsule endoscopy
- small bowel follow through x-rays
- CT enteroclysis: double contrast imaging of the small bowel
