GI Bleeding Flashcards
GI bleeding definition
pertains to every form of hemorrhage in the GI tract from the pharynx to the rectum
Upper GI bleeding
hemorrhage from any source between the pharynx and ligament of Treitz
Considered medical emergencies
What is an upper source of GI bleeding usually characterized by?
Hematemesis and melena
Dx made more easily when pt has hematemesis
Esophageal varices
Potential source of upper GI bleeding
Emergent tx of esophageal varices
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)
Therapeutic tx of esophageal varices
Variceal ligation (banding) Sclerotherapy
Potential causes of upper GI bleeding
Bleeding esophageal varices Mallory-Weiss tears Esophageal rupture Boerhaave's syndrome Bleeding gastric varices Angiodysplasia Cancer
How do pts w/ upper GI bleeding due to peptic ulcer dz often present?
Hematemesis
Coffee ground vomiting
Melena
Hematochezia
May also present w/ complications of anemia such as fatigue, syncope and SOB
Boerhaave’s Syndrome
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
Caput Medusa
Appearance of distended and engorged peri-umbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins
Medications that increase the risk of upper GI bleeds
ASA and NSAIDs (4x increased risk)
SSRIs
Corticosteroids
Anticoagulants
Initial PE for upper GI bleed
- VS: determine severity of bleeding and timing of intervention
- CV and lung exam
- Abdominal and rectal exam –> to determine possible causes of hemorrhage
- Assess for portal hypertension and stigmata of chronic liver dz to see if bleeding is coming from a variceal source
Recommended labs for upper GI bleeds
CBC
Coagulation time
Electrolytes
Cross matching of blood for possible later transfusion
Diagnostic and tx option of first choice for upper GI bleeds
Emergency upper endoscopy
Glasgow-Blatchford bleeding score
Score equal to “0” is low. Requirements:
- Hgb level >12.9 g/dL (men) or >11.9 g/dL (women)
- Systolic BP >109 mmHg
- Pulse
Lower GI bleed definition
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
Potential causes of lower GI bleeds
- diverticulosis, diverticulitis
- Crohn’s
- UC
- Ischemic colitis
- Infectious colitis
- Angiodysplasia
- Neoplasm, polyps, cancer
- Hemorrhoids
Melena
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
Hematochezia
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
Where are diverticula most commonly located?
Sigmoid and descending colon
True diverticula
includes all layers of bowel wall
False diverticula
Includes serosa and mucosal layer of bowel wall
Right sided diverticula are responsible for what % of lower GI bleeding secondary to diverticulosis?
50-90%!
However, 75% of diverticula occur on the left side of the colon
Colorectal carcinoma
Causes occult bleeding as a result of mucosal ulceration or erosion
Third most common cancer in the US
Colorectal adenocarcinoma
Ulcerative Colitis
Causes bloody diarrhea in most cases
In up to 50% of UC pts mild to moderate LGIB occurs
Approximately 4% have massive bleeding
Crohn’s Dz
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
Ischemic colitis
Dz of the elderly, commonly observed in the 6th decade of life
Ischemia causes mucosal and partial-thickness colonic wall sloughing, edema and bleeding
Where does ischemic colitis often times occur?
Frequently involves splenic flexure and recto-sigmoid junction
What is the most common form of ischemic injury to the digestive system?
Ischemic colitis
Main clinical manifestations of ischemic colitis
Abdominal pain & bloody diarrhea
Infectious colitis pathophysiology
May be due to colonic tissue invasion by bacteria such as salmonella or shigella or toxin-mediated damage as with E. coli 0157:H7
Angiodysplasia
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.
Risk factors for increased morbidity and mortality with lower GI bleeds
Poor renal function
Age >60 years
Abnormally low BP
Persistent bleeding within first 24 hours of presentation
Standard of care for dx of lower GI bleeds
colonoscopy
When is angiography performed with a lower GI bleed?
In hemodynamically unstable patients and in those w/ brisk ongoing LGIB
OR
If colonoscopy has failed to identify a bleeding site
3 components of the management of LGIB
- Resuscitation and initial assessment
- Localization of the bleeding site
- Therapeutic intervention to stop bleeding at the site
Indications for surgery w/ LGIB
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
Therapeutic options for diverticular bleeding
Colonoscopy w/ electric cauterization, epi injection or placement of metallic clips
Therapeutic options for recurrent bleeding
Resection of the affected bowel segment
Therapeutic options for angiodysplasia
Electrocoagulation or laser coagulation
