GI Bleeding

Question 1

What is the first priority in evaluation of someone with a GI bleed?

Answer 1

assessing/stabilizing ABC
airway
breathing
circulation

pertinent labs: CBC, electrolyte, LFTs, PT and PPT, type and cross are commonly assessed

later assess risk factors and find source of bleeding: endoscopy, colonoscopy, angiography etc.

Question 2

What are risk factors for acute GI bleed?

Answer 2

NSAID use
etiologies are often age specific
underlying liver disease
hx of diverticulosis or AAA repair

Question 3

If a patient with GI bleed presents requiring fluid recitation, what is important to remember?

Answer 3

2 large bore IVs or a central line to administer blood products or fluids
blood type and cross match may also be prudent

Question 4

An elevated BUN: Cr ratio may mean what regarding GI bleed?

Answer 4

may suggest an upper GI bleed (BUN rises due to the breakdown of blood proteins to urea by intestinal bacteria which is then reabsorbed)

Question 5

What is the line of demarcation between upper and lower GI bleeds?

Answer 5

ligament of Treitz

Question 6

What are the top 3 causes of upper GI bleed?

Answer 6

duodenal ulcer, gastric ulcer or varicies

Question 7

What are adverse clinical prognostic factors of UGI bleed?

Answer 7

shock, red blood in stool
varicieal or cancerous cause of bleeding
older age
onset in the hospital
recurrent bleeding

endoscope: active bleeding, bleeding from varies, large ulcer, visible vessel, dangerous location of ulcer

Question 8

How does units transfused have prognostic value?

Answer 8

over 6 units since admission, prognosis starts to deteriorate
co-morbid diseases also contribute to poor prognosis

Question 9

What is a Mallory Weiss tear? What is a common accompanying hx? How do you treat?

Answer 9

tear at the gastroesophageal junction, often accompanied by a history of recurrent retching prior to development

bleeding can stop spontaneosly, treat with hemoclips, injection of epineprine and observation

Question 10

What are common causes of esophagitis leading to erosion/ulceration and how is it treated?

Answer 10

reflux, radiation, Candida, CMV, erosive effects of pills in the esophagus

tx. with acid suppression, stop offending meds, treat infection

Question 11

What other symptom may occur leading up to bleed caused by esophageal cancer?

Answer 11

history of dysphagia to solid foods

tx is often surgical, slow bleeding with injection of pi or hemoclips

Question 12

What is the purpose of a Sengstaken blakemore tube?

Answer 12

two balloon system that is inflated and then braced with traction to hold pressure against the esophagus

Question 13

Order the different characteristics of ulcers by the severity of bleeding (visible cells, spurting, oozing, adherent clot)

Answer 13

active bleed, non-bleeding visible vessel, clot, dot, clean base

bleeding risk decreased with IV PPIs

Question 14

Characterize the bleeding due to gastritis and portal gastropathy.

Answer 14

gastritis: bleeding is usually minor

portal gastrophathy can be chronic as well as acute

Question 15

What is a Dieulafoy’s vessel?

Answer 15

abnormally large submucosal artery that can rupture and cause a moderate to severe bleed (tx. with hemoclips, epi injection, surgery or angioembolization)

Question 16

What clinical context is likely in the case of a bleed caused by aortoenteric fistula (pt. hx, location of bleed etc.)

Answer 16

75% occur in the third portion of the duodenum
most commonly in the situation of graft repair
** 50% will have a herald bleed that stops spontaneously hours to days before the massive bleed

tx is usually with surgery- TX required VERY QUICKLY

Question 17

How are AVMs treated and what conditions are they commonly associated with?

Answer 17

AVMs are associated with chronic renal failure, aortic stenosis, and radiation therapy

can be a source of acute and chronic bleeding, treated with argon plasma coagulation

Question 18

_____ accounts for 30-50% of all cases of lower GI bleeding, bleeding stops spontaneously in about 75% of patients.

Answer 18

Diverticulosis

Question 19

What diagnostic tool is used specifically to find the bleed in diverticulosis?

Answer 19

tagged RBC scan to localize bleeding because endoscopy is often difficult to use finding a single tic that is bleeding

Question 20

T/F Colitis is a common cause of major lower gastrointestinal hemorrhage.

Answer 20

False: overall, major hemorrhage is uncommon for Crohn’s, infectious, C. diff, Ulcerative, and Ischemic colitis.

Question 21

What symptoms usually accompany hemorrhoids as the cause of lower GI bleed?

Answer 21

hx. of recent constipation with straining and passage of brown stool with bright red blood, digital rectal exam will be very helpful in dx.

use observation and stool softners for repeat bleeding

Question 22

Contrast occult and obscure bleeding.

Answer 22

occult: patient not aware of bleeding (often found by anemia or recurrent guaiac + stool) should be worked up to exclude colon cancer
obscure: bleeding apparent to patient but location of bleed is not readily clear

Question 23

Describe the work up (type of imaging) useful in occult/obscure bleeding.

Answer 23

1. repeat EGD and colonoscopy
2. further evaluation of the small intestine by push enteroscopy, double balloon eneteroscopy, capsule endoscopy, sm. bowel follow through X-rays, CT enteroclysis
3. active bleed: tagged RBC scan