GI Bleeding Flashcards
Hematemesis
bright red blood in vomit, or coffee ground type material
Melena
black, tar like stool
Hematochezia
BRBPR (bright red blood per rectum), usually lower, but if
massive upper GIB, can have this
Esophagus spinal level
T2-T8
Spinal level for Upper GI Tract
Stomach, Liver, Gallbladder, Spleen, Portions of Pancreas and Duodendum
T5-T9, Greater Splanchnic Nerve Celiac Ganglion
Spinal level for Middle GI Tract
Portions of Pancreas and Duodenum, Jejunum, Ileum, Ascending Colon, and 2/3 of Transverse Colon
T10-T11, Lesser Splanchnic Nerve Superior Mesenteric Ganglion
Lower GI Tract
Distal 1/3 of Transverse Colon, Descending Colon and Sigmoid Colon, Rectum
T12-L2, Least Splanchnic Verse Inferior Mesenteric Ganglion
Acute upper GI bleed can be from
- Peptic Ulcer Disease (H pylori)
- Portal Hypertension: 10-20% of cases; can be massive due to esophageal or gastric varices; pressures in portal system, draining into liver, esophageal varices are very risky if they start bleeding
- Mallory Weiss tear
Initial step for acute GI bleed
- NG tube? Gastric Lavage?
- Rectal?
- Hemodynamic Stabilization
- -BP Systolic 100 response to acute
- -blood loss, first vital sign of change
- HCT takes 24-72 hours to equilibrate
- Two large 18 gauge IV’s
- Type and Screen, CBC, INR/PT/PTT, CMP
- 0.9% NS until blood ready, if needed can use O – blood universal donor
- ICU? Central line?
- Give bolus of IV saline until you can see what hemoglobin levels are
Goal of hemoglobin?
New guidelines:
- 7 is threshold now, unless cardiac history then consider goal of >9 (if having MI; want to increase oxygenation to cardiac muscle)
- Platelets > 50,000
-Warfarin? INR high? Give FFP
Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC
Uremia? End Stage Renal Disease patient? Consider _________
DDAVP (desmopressin acetate, synthetic ADH)
-in pts with uremia, platelets are there but don’t stick together well bc of uremia, DDAVP helps promote platelet adhesion, makes them sticky again
History items to consider during acute upper GI bleed
- Aspirin? Cant reverse- takes 10-14 days to get our of your system (Clopridogrel and ASA- platelets are irreversibly inhibited)
- NSAIDS? Cant reverse
- NOAC? Novel oral anticoagulation
- Cirrhosis? Think esophageal varices
-WHEN WAS THE LAST DOSE TAKEN?
Role of upper endoscopy in acute upper GI bleed
- Stabilize patient first hemodynamically
- Cautery, injection, endoclips
- Banding varices
- Bleeding ulcer or vessel: vessel they can clip, clips fall off on their own
- Put rubber bands on esophageal varices to prevent them from bleeding/rupturing
Pharmacologic therapy for acute upper GI bleed
-IV PPI (bolus then drip for 72 hours)
-Consider PO PPI if low risk features
-Octreotide: gastric varices in liver patients, prevent them from bleeding worse if they have a small bleed- given IV
Patient’s with esophageal or gastric varices, liver disease, portal HTN; Reduces splanchnic blood flow and portal blood pressures
Long term side effects with PPI use
- Potential decrease in non heme iron absorption with PPI has not been well studied
- No good evidence to support PPI use affecting bone density or osteoporosis related fractures
- ~50 cases of hypomagnesemia associated with PPI use
- FDA recommended consider checking magnesium level before starting long term PPI therapy
Acute lower GI bleed
- Hematochezia
- 10% due to upper source
- Lower definition: below ligament of Treitz
Causes of acute lower GI bleed
- Diverticulosis (can erode a blood vessel and bleed; acute, painless, large volume possible)
- Angioectasia: more common in CKD/ESRD patients
- Neoplasms
- IBD
- Anorectal disease (hemorrhoids, fissures)
- Ischemic Colitis (older pt, nonocclusive ischemia, usually self limited)
- Radiation induced proctitis (can irritate mucosa)
Test for acute lower GI bleed
-Exclude upper GIB (NGT, lavage)
-Rectal Exam
-Colonoscopy or sigmoidoscopy
(Prep with GoLYTELY 3.8L)
-NM PRBC Scan (if positive, next step is angiography; Localization is poor, and
Crohn’s vs UC: Site of origin
C- terminal ileum
UC- rectum
Crohn’s vs UC: Pattern of progression
C- Skip lesions/irregular
UC- proximally contiguous
Crohn’s vs UC: Thickness of inflammation
C- transmural (across wall)
UC- submucosa or mucosa
Crohn’s vs UC: Symptoms
C- crampy abdominal pain
UC- bloody diarrhea
Crohn’s vs UC: Complications
C- fistulas, abscess, obstruction
UC- hemorrhage, toxic megacolon
Crohn’s vs UC: Radiographic findings
C- string sign on brain X-ray
UC- lead pipe colon on barium X-ray
Crohn’s vs UC: Risk of colon cancer
C- slight increase
UC- marked increase
Crohn’s vs UC: Surgery
C- for complications such as stricture
UC- curative (take out whole colon to rule out cancer, use colostomy bag)
Transfusion in acute upper GI bleed
- Restrictive strategy group threshold of 7 g/dl (Goal 7-9)
- Liberal group threshold of 9 g/dl (Goal 9-11)
- Mortality at 45 days lower in restrictive strategy group 23/444 vs. 41/445
- Subgroup with cirrhosis, risk of death was lower in restrictive strategy group 15/139 vs. 25/138
New anticoagulants in GI bleed
Pradaxa – dabigatran
Xarelto – rivaroxaban
Eliquis - apixaban
-metabolized in kidney, warfarin is in liver
-Expensive, don’t have to get INR checked regularly
Coumadin, Warfarin take 72 hours to become activated and work
- These meds start working within hours- advantage if you are already bleeding- within 24-48 hrs they are out of your system
- Direct factor 10a inhibitors (3 of them)
- Block thrombin (1 of them)
see slide 26
see slide 26
New anticoagulant risks
- Lower risk of hemorrhagic stroke brain bleed
- Higher risk of GI bleed
When to resume Warfarin after GI bleed
- GIB defined by HGB drop by 2 grams, visible bleeding, or positive endoscopic evaluation
- Restarting warfarin after 7 days was NOT associated with increased risk of GIB, but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption.
Put older people on anti platelet therapy to prevent
them from bleeding (on steroids, NSAIDS, put them on pentoprazol to prevent a bleeding ulcer, even with the risk of C diff)
INR goal of 2-2.5 is recommended for
-Combination of aspirin and heparin/LMWH/warfarin or clopidogrel
Use of low dose aspirin for cardiovascular prophylaxis associated with
2-4 fold increase in upper gastrointestinal events
-AHA recommends low dose aspirin in patient with 10 year cardiovascular risk > or = 10%
-Full 325 ASA for prevention- very high bleeding risk- don’t need to use this
81 mg does just as good and has LOWER bleeding risk
Gastric ulcer indication
Greater pain with meals
Duodenal ulcer indication
Decreased pain with meals
Ischemic colitis indication
post-prandial abdominal pain, older patient, hematochezia
H2 blockers
famotidine, ranitidine – Block H2 receptors of parietal cells
PPIs
omeprazole, pantoprazole
- Inhibit H+/K+ ATPase in parietal cells
- Low magnesium levels possible with long term use, higher risk of C diff
Magnesium
Makes you go, take for constipation
Aluminium
minimum amount of feces, take for diarrhea
Osmotic laxatives
PEG, lactulose
