GI Bleeding

Question 1

GI bleeding definition

Answer 1

pertains to every form of hemorrhage in the GI tract from the pharynx to the rectum

Question 2

Upper GI bleeding

Answer 2

hemorrhage from any source between the pharynx and ligament of Treitz

Considered medical emergencies

Question 3

What is an upper source of GI bleeding usually characterized by?

Answer 3

Hematemesis and melena

Dx made more easily when pt has hematemesis

Question 4

Esophageal varices

Answer 4

Potential source of upper GI bleeding

Question 5

Emergent tx of esophageal varices

Answer 5

Care directed at sopping blood loss, maininting plasama volume, correcting disorders in coagulation induced by cirrhosis and appropriate use of abx (infxn by gram- organisms commonly concomitant or precipitant)

Question 6

Therapeutic tx of esophageal varices

Answer 6

Variceal ligation (banding)
Sclerotherapy

Question 7

Potential causes of upper GI bleeding

Answer 7

Bleeding esophageal varices
Mallory-Weiss tears
Esophageal rupture
Boerhaave's syndrome
Bleeding gastric varices
Angiodysplasia
Cancer

Question 8

How do pts w/ upper GI bleeding due to peptic ulcer dz often present?

Answer 8

Hematemesis
Coffee ground vomiting
Melena
Hematochezia

May also present w/ complications of anemia such as fatigue, syncope and SOB

Question 9

Boerhaave’s Syndrome

Answer 9

spontaneous perforation of the esophagus that most commonly results from a sudden increase in intra-esophageal pressure combined with negative intra-thoracic pressure such as in straining, coughing or vomiting

Question 10

Caput Medusa

Answer 10

Appearance of distended and engorged peri-umbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins

Question 11

Medications that increase the risk of upper GI bleeds

Answer 11

ASA and NSAIDs (4x increased risk)
SSRIs
Corticosteroids
Anticoagulants

Question 12

Initial PE for upper GI bleed

Answer 12

1. VS: determine severity of bleeding and timing of intervention
2. CV and lung exam
3. Abdominal and rectal exam –> to determine possible causes of hemorrhage
4. Assess for portal hypertension and stigmata of chronic liver dz to see if bleeding is coming from a variceal source

Question 13

Recommended labs for upper GI bleeds

Answer 13

CBC
Coagulation time
Electrolytes
Cross matching of blood for possible later transfusion

Question 14

Diagnostic and tx option of first choice for upper GI bleeds

Answer 14

Emergency upper endoscopy

Question 15

Glasgow-Blatchford bleeding score

Answer 15

Score equal to “0” is low. Requirements:

1. Hgb level >12.9 g/dL (men) or >11.9 g/dL (women)
2. Systolic BP >109 mmHg
3. Pulse

Question 16

Lower GI bleed definition

Answer 16

A bleed that occurs distal to the ligament of Treitz including the last 1/4 of the duodenum and entire area of jejunum, ileum, colon, rectum and anus

Question 17

Potential causes of lower GI bleeds

Answer 17

1. diverticulosis, diverticulitis
2. Crohn’s
3. UC
4. Ischemic colitis
5. Infectious colitis
6. Angiodysplasia
7. Neoplasm, polyps, cancer
8. Hemorrhoids

Question 18

Melena

Answer 18

Black tarry appearing stools that usu indicate blood that has been in the GI tract for at least 8 hours

4x more likely to come from an upper GI bleed than lower GI

Question 19

Hematochezia

Answer 19

Bright red or maroon colored stool
Sign or a significantly active GI bleed

6x more likely to represent a lower GI bleed instead of an upper bleed

Question 20

Where are diverticula most commonly located?

Answer 20

Sigmoid and descending colon

Question 21

True diverticula

Answer 21

includes all layers of bowel wall

Question 22

False diverticula

Answer 22

Includes serosa and mucosal layer of bowel wall

Question 23

Right sided diverticula are responsible for what % of lower GI bleeding secondary to diverticulosis?

Answer 23

50-90%!

However, 75% of diverticula occur on the left side of the colon

Question 24

Colorectal carcinoma

Answer 24

Causes occult bleeding as a result of mucosal ulceration or erosion

Question 25

Third most common cancer in the US

Answer 25

Colorectal adenocarcinoma

Question 26

Ulcerative Colitis

Answer 26

Causes bloody diarrhea in most cases In up to 50% of UC pts mild to moderate LGIB occurs Approximately 4% have massive bleeding

Question 27

Crohn's Dz

Answer 27

1-2% of pts with Crohn's may experience massive bleeding | Frequency of bleeding more common w/ colonic involvement than with small bowel involvement alone

Question 28

Ischemic colitis

Answer 28

Dz of the elderly, commonly observed in the 6th decade of life Ischemia causes mucosal and partial-thickness colonic wall sloughing, edema and bleeding

Question 29

Where does ischemic colitis often times occur?

Answer 29

Frequently involves splenic flexure and recto-sigmoid junction

Question 30

What is the most common form of ischemic injury to the digestive system?

Answer 30

Ischemic colitis

Question 31

Main clinical manifestations of ischemic colitis

Answer 31

Abdominal pain & bloody diarrhea

Question 32

Infectious colitis pathophysiology

Answer 32

May be due to colonic tissue invasion by bacteria such as salmonella or shigella or toxin-mediated damage as with E. coli 0157:H7

Question 33

Angiodysplasia

Answer 33

Arteriovenous malformations located in the cecum and ascending colon Most = degenerative lesions that come from chronic, intermittent, low-grade colonic contraction that obstructs the mucosal venous drainage.

Question 34

Risk factors for increased morbidity and mortality with lower GI bleeds

Answer 34

Poor renal function Age >60 years Abnormally low BP Persistent bleeding within first 24 hours of presentation

Question 35

Standard of care for dx of lower GI bleeds

Answer 35

colonoscopy

Question 36

When is angiography performed with a lower GI bleed?

Answer 36

In hemodynamically unstable patients and in those w/ brisk ongoing LGIB OR If colonoscopy has failed to identify a bleeding site

Question 37

3 components of the management of LGIB

Answer 37

1. Resuscitation and initial assessment 2. Localization of the bleeding site 3. Therapeutic intervention to stop bleeding at the site

Question 38

Indications for surgery w/ LGIB

Answer 38

Persistent hemodynamic instability with active bleeding Persistent, recurrent bleeding Transfusion of more than 4 units packed RBCs in a 24-hour period w/ active or recurrent bleeding

Question 39

Therapeutic options for diverticular bleeding

Answer 39

Colonoscopy w/ electric cauterization, epi injection or placement of metallic clips

Question 40

Therapeutic options for recurrent bleeding

Answer 40

Resection of the affected bowel segment

Question 41

Therapeutic options for angiodysplasia

Answer 41

Electrocoagulation or laser coagulation