GI Bleeding Flashcards
What anatomical feature distinguishes between upper and lower GI?
Ligament of Trietz; at the duodenojejunal junction.
Presentation of Upper GI bleeding
- hematemesis (bright red blood)
- blood or coffee grounds detected during nasogastric lavage
- melena (black/sticky feces); may be as little as 50-100mL
- BUN to serum creatinine ratio greater than 30
Lower GI bleeding presentation
- blood clots in stool
- red blood that is mixed with solid brown stool
- dripping of blood into toilet after a BM
- hematochezia: red or maroon colored stool
When might you see hematochezia? What color is it?
generally from lower GI source but can occur with a loss of more than 1000mL of blood in the upper GI tract.
Red/maroon colored stool
What causes coffee-ground emesis?
blood sitting in the stomach acid causes the iron to oxidize resulting in the appearance of coffee ground-like flakes.
Describe the features of Upper and Lower GI bleeding:
- severity
- site
- presentation
- nasogastric lavage
- bowel sounds
- BUN/Creat Ratie
Upper GI (2/3 of casses): -severity: more likely to have significant bleeding
- site: above the ligament of trietz
- presentation: hematemesis, melena, heamtochezia with massive UGI of greater than 1000mL
- nasogastric lavage: blood
- bowel sounds: hyperactive
- BUN/Creat: greater than 30:1
Lower GI Bleed:
-severity: likely to present with shock or require transfusion
- Site: below the ligament of trietz
- presentation: hematochezia (red/maroon)
- nasogastric lavage: clear fluid
- Bowel sounds: normal
BUN/Creat: normal
Where does BUN come from?
when protein is used for energy the carbon is cleaved from the amino acid and leaves behind a nitrogen. The N takes up 3H+ creating ammonia.
Ammonia processed through the liver to become urea, once it enters the blood stream it is called BUN.
Top 3 etiologies of Upper GI bleeds
- peptic ulcer dz (NSAIDS, PUD)
- portal HTN (cirrhosis, varices)
- Mallory-Weiss Tears (retching, ETOH)
Upper GI bleed Causes:
- vascular anomalies; what are these?
- what are some other causes that are cause less significant bleeding?
Vascular anomalies: angiodysplasia & telangectasias (associated with CT dz like CREST and HTT)
HTT = hereditary hemorrhagic telangectasia; these bleed all the time.
Other causes:
- gastric neoplasm
- erosive gastritis
- erosive esophagitis
- aortoenteric fistula
- hepatic tumor
- angioma
- penetrating trauma
- pancreatic malignancy
Etiology of Lower GI bleeding:
- less than 50YO
- greater than 50 YO
Less than 50:
- infectious colitis
- anorectal dz (hemorrhoids, fissures; bright red blood noted on toilet paper, blood streaked stool)
- inflammatory bowel Dz (primarily ulcerative colitis)
Greater than 50:
- diverticulosis
- angioectasia
- malignancy
- ischemia (may also be seen in younger patients post long distance running)
What causes 50% of Lower GI bleeds?
Etiology of acute, painless, large volume of maroon or bright red hematochezia?
Diverticulosis causes 50% of lower GI bleeds.
Diverticulitis
Initial Management of GI Bleeding
Stabilization:
Blood Replacement:
GI consult for upper or lower endoscopy
Labs: CBC, PT/INR, CMP, Blood Types and screening
Assessing the degree of bleeding:
- what SBP and HR is noted with
- -severe bleeding
- -moderate bleeding
- -minor bleeding
Severe: SBP less than 100mmHg & HR greater than 100BPM
Moderate: SBP greater than 100mmHg & HR greater than 100BPM
Minor: normal BP and HR
WHat do you do to stabilize a patient with GI bleeding??
- 2 large bore IVs
- NS or lactated ringer solution
- NG tube +/- (can lavage with saline and aspirate contents looking for blood to confirm upper souce)
- IV PPI for UGI
- IV octreotide or somatostatin to reduce splanchnic blood flow and portal pressures if d/t varices from portal HTN.
blood replacement in GI bleeding:
- what is target hgb?
- how many units RBC raises hgb 1g/dL?
- what is the RBC/FFP ratio?
- when do you transfuse platelets?
- at what INR level do you need to give FFP?
- uremic pts may benefit from what medications?
- target is to maintain Hgb of 7-10g/dL
- hgb should increase 1g/dL for each unit transfused
- give one unit of FFP for each 5 units of packed RBC
- transfuse platelets if less than 50K and actively bleeding
- FFP if INR greater than 1.8
- uremic pts may benefit from DDAVP (activates VW factor)
