GI bleeding Flashcards
What is the differentiation point for the upper and lower GI bleeding?
Ligament of Trietz (LoT) is at the duodenojejunal junction
-Upper GI bleed
From a source above the LoT
-Lower GI bleed
From a source below the LoT
Presentation of Upper GI bleeding
4
- Hematemesis
- Blood or coffee grounds detected during nasogastric lavage
- Melena
- BUN to serum creatinine ratio greater than 30
Presentation of Lower GI bleeding
3
- Blood clots in the stool
- Red blood that is mixed with solid brown stool
- Dripping of blood into the toilet after a bowel movement
- Hematemesis will look like what?
- Melena can occur with just how much blood loss in the upper GI tract?
- Hematochezia is what color?
- Hematochezia is generally caused by what but can also be caused by?
- Red or brown flakes like coffee grounds
- 50-100 mL of blood
- Red or maroon colored stool
- Generally from a lower GI source but can occur with a loss of more than 1000 mL of blood in the upper GI tract
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 following for Upper GI bleeds and also for Lower GI bleeds: 1. Severity? 2. Site? 3. Presentation? Upper- 3 Lower -1 4. Nasogastric lavage? 5. Bowel sounds? 6. BUN:Creat ratio?
Upper GI Bleed (2/3 of cases of GIB) 1. More likely to have significant bleeding 2. Above the Ligament of Trietz 3. -Hematemesis, -melena, -Hematochezia with massive UGI of > 1000 mL 4. Blood 5. Hyperactive 6. > 30:1
Lower GI Bleed
- Less likely to present with shock or require transfusion
- Below the Ligament of Trietz
- Hematochezia
- Clear fluid
- Normal
- Normal
Review: Where does BUN come from?
5 steps
- When protein is used for energy the carbon is cleaved from the amino acid and leaves behind a Nitrogren.
- The N takes up 3 H+ to form NH3+ which is ammonia.
- The ammonia (NH3+) is then processed through the liver to become urea.
- When the urea enters the blood stream it is called the blood urea nitrogren.
- The blood urea nitrogren is then excreted by the kidney
BUN increases when protein is broken down and more ammonia forms
Examples? 6
- Burns
- Tetracycline
3 Steroids - Fever
- Catabolic state
- Upper GI bleeding
How does Upper GI bleeding cause increased BUN?
(breakdown of the hemoglobin protein by the stomach acid, enzymes)
Etiology of Upper GI bleeds?
(in order of prevelance)
8
- Peptic ulcer dz 50%
- Portal HTN 20%
- Mallory-Weiss Tear 10%
- Vascular anomalies 7%
- Others 6%
- Erosive Gastritis 5%
- Erosive esophagitis 1%
- Gastric neoplams 1%
- Portal HTN is most commonly caused by?
2. Results in formation of what? 3
- Most common cause is cirrhosis
- Results in formation of
- esophageal,
- gastric and
- duodenal varices that can rupture
- What is a mallory weiss tear?
- Most often caused by?
- Other causes? 6
- Laceration of the gastroesophageal junction
- Often report a history of retching which may be due to heavy drinking
- Seizure,
- childbirth,
- coughing,
- straining,
- defecation,
- weight lifting
Vascular anomalies that cause UGI bleeding?
2
- Angiodysplasia
2. Telangectasias
- Angiodysplasia are what?
2. Telangectasias associated with what?
- Small AV malformations
2. Associated with connective tissue disease like CREST syndrome and HHT
- Erosive gastritis is usually described as what kind of bleeding?
- Erosive esophagitis secondary to what?
- Usually superficial bleeding that does not lead to acute significant blood loss
- Secondary to chronic reflux
“Other” causes of UGI
5
- Aortoenteric fistula
- Hepatic tumor
- Angioma
- Penetrating trauma
- Pancreatic malignancy
Other causes of UGI: Aortoenteric fistula. What is it?
Complication post abdominal aortic aneurysm (initial presentation or post graft placement)
Etiology of LGI bleeding
- If age younger than 50? 3
- If age older than 50? 4
- Age 50
- Diverticulosis
- Agioectasias
- Malignancy
- Ischemia
Etiology of Lower GI bleeding Diverticulosis: 1. Causes what % of LGIs? 2. What increases the risk of bleeding with diverticulosis? 2 3. Presents how?
- Causes 50% of LGIs
- ASA and NSAIDs
- Acute, painless, large volume maroon or bright red hematochezia
Etiology of Lower GI bleeding:
Angioectasias
1. Presents how?
2. Most common in what ages?
- Painless bleeding in the upper or lower GI tract
2. Most common in > 70 years
Anorectal disease causes of LGI? 2
What will it look like?
- Hemorrhoids and fissures
2. Bright red blood noted on toilet paper, blood streaked stool or blood dripping into toilet
Ischemic colitis
- Most often in pts with what?
- Can be a complication of what?
- When would it be seen in younger pts?
- Most often older patients with atherosclerotic disease
- Can be a complication of aortic surgery
- Can be seen in younger patients post long distance running
When would Radiation induced proctitis present?
Months to years post pelvic radiation
Initial management of bleeds
3
- Stabilization
- Blood replacement
- GI consult for Upper or lower endoscopy
Assess the degree of bleeding from SBP and HR
- Severe?
- Moderate?
- Minor bleeding?
- Severe bleeding
SBP less than 100 mmHg
HR > 100 - Moderate bleeding
SBP > 100 mmHg
HR > 100 - Minor bleeding
Normal HR and BP
Labs for bleeding?
4
- CBC
- -May take 24 hours to reflect the degree of blood loss - PT/INR
- CMP
- Blood type and screening
Stabilization
of bleeding?
4
- 2 large bore IV’s
- NS or Lactated Ringer solution
- Nasogastric tube +/-
- IV proton pump inhibitor for UGI
Why would we consider a nasogastric tube?
Can lavage with saline and aspirate contents looking for blood to confirm upper source
If due to varices from portal HTN then can give what?
2
IV octreotide or somatostatin to reduce splanchnic blood flow and portal pressures
Transfusion
1. Usually target is to maintain Hgb of what?
- How much should Hgb go up per each unit transfused?
- Give one unit of FFP for each _______ of packed red blood cells
- Transfuse platelets if
- 7-10 g/dL
- 1 g/dL for each unit transfused
- 5 units
- 1.8
- DDAVP
Endoscopy
1. Unless very unstable usually prefer to do a what?
- Upper endoscopy, can help enhance stomach emptying by the administration of what?
- Endoscopy can be both…?
- bowel prep if colonoscopy is needed
- IV erythromycin
- diagnostic as well as therapeutic
What kind of therapeutic measures can we take with endoscopy? 2
- Sclerosis or banding of varices
2. Cautery of bleeding vessels
Treatment:
Depending on the underlying cause of the GI bleeding? 3
- May require surgical repair
- Intra-arterial embolization (done percutaneously)
- Decompression of the portal vein with a shunt placement if varices are not manageable
- If abdominal pain and periotoneal signs consider there is a what?
- If may take the HCT __ hrs or more to reflect the current state of blood volume, so act clinically
- Bowel of esophageal perforation
2. 24
The higher the BUN:creat ratio the more likely the bleeding is from what?
upper GI source
- Acute blood loss anemia?
2. Chronic?
- Normocytic/ Just low
2. Microcytic
