GI bleeding

Question 1

occult GI bleeding suggestive symptoms

Answer 1

symptoms of anemia, iron deficiency or microcytosis, heme positive stools

Question 2

what is occult GI bleeding defined as

Answer 2

positive fecal occult blood test with or without Fe deficiency anemia in absence of visible blood loss

Question 3

what causes occult GI bleeding?

Answer 3

malignancy, peptic ulcers, vascular malformations, diverticula, inflammatory bowel dx

Question 4

what is next step in evaluation of occult GI bleed if EGD and colonscopy are negative?

Answer 4

need a to look at small bowel with a wireless capsule endoscopy

Question 5

adult meckel’s diverticulum

Answer 5

asymptomatic but can have painless GI bleeding in pts <2 yrs rare in pts >40 yrs.

Question 6

when to order a radionuclide scan?

Answer 6

detects over GI bleeding and bleeding must be fairly rapid (0.1-0.5ml/min)

Question 7

when to order a enteroclysis or double contrast study with injection barium and air into a tube that is passed through the small bowel

Answer 7

low diagnostic yield <20% and only performed if cannot do a capsule endoscopy

Question 8

GI bleed algorithm

Answer 8

Question 9

Transfusion goal is

Answer 9

Hgb>7

Question 10

transfusion goal if they have possible variceal bleeding

Answer 10

Keep INR<3 for EGD and Plt >50 and can get FFP when appropriate

Question 11

Severe anemia such as those with unstable coronary artery disease goal

Answer 11

Hgb >9 esp if they have unstable angina or ACS

Question 12

Mallory Weiss tear is

Answer 12

upper GI mucosal tear with sudden increase in intraabdominal pressure from forceful retching

can cause subcuosal arterial or venule plexus bleeding.

Question 13

Pts typically present with epigastric pain radiating to back and hematemesis after extended nausea and vomiting.

Answer 13

Mallory weiss tear

= bleeding is self limited to 24-48 hrs of bleeding.

Question 14

How to evaluate and diagnose MW tear

Answer 14

EGD - done mostly to rule out other conditions like esophagitis from reflux, infection, pill induced

MW tears cause self limited bleeding. Usually located near distal esophagus and proximal stomach.

Treat with PPI but benefit is not clear.

Question 15

threshold for safely doing urgent EGD based on INR

Answer 15

INR <1.5-2.5

Question 16

Initial management of upper GI bleed:

(management based on EGD results)

Answer 16

IVFs,

high dose IV PPI

urgent EGD in first 24 hrs of presentation.

ulcers are generally related to H pylori and NSAID use but there are some high, intermediate, and low risk features of an ulcer.

High risk ulcers predict risk for rebleeding and so need endoscopic treatment

Question 17

High risk ulcers in GI bleed are important because

Answer 17

High risk ulcers predict risk for rebleeding and so need endoscopic treatment

High risk features of an ulcer seen on EGD: active bleeding, adherent clot, visible vessel

need endoscopic treatment.

Question 18

What is the risk for rebleeding in a patient with GI bleed who gets EGD?

Answer 18

depends upon the ulcer type - if high risk or low risk.

Most rebleeding happens in first 72 hrs of and so need to monitor pts on high dose PPI therapy.

Give clear liquid diet as advised because urgent EGD for repeat endoscopy may be needed if rebleeding occurs.

If intermediate risk ulcer, can trial clear liquid diet and eradicate bleeding.

Low risk ulcers - once daily PPI can try regular diet nad

Question 19

who goes to the ICU for GI bleed?

When do we start octreotide?

Answer 19

Hemodynamically unstable or actively bleeding pts should go to ICU

octreotide is not recommended for routine use in pts with acute nonvariceal bleeding e_xcept in unstable pts awaiting definitive EGD treatment or when endoscopy is contraindicated_ or not available.

Question 20

after treatment with EGD for a high risk ulcer what should GI bleed patients get?

Answer 20

clear liquid diet for 2 days

continued high dose IV PPI For 3 days to minimize bleeding risks

Question 21

Causes of lower GI bleeding include:

Answer 21

anatomical conditions - diverticulosis

vascular causes - arteriovenous malformations AVMs

inflammatory dx (inflammatory bowel disease)

malignancy.

Question 22

intestinal angiodysplasia or AVM is seen in which people?

also how does it cause issues?

Answer 22

AVMs are abnormal connections between arteries and veins nad htis can erode throught he GI muscosa and bleed.

Angiodysplasia presents in patients >60 yrs and occur in 1 or multiple areas of GI tract

seen in aortic stenosis and ESRD pts

Question 23

what is the connection between GI bleeds and AVMs and aortic stenosis?

Answer 23

Heyde syndrome-

see tubulent blood flow through the tight aortic valve and this causes disruption of von Willebrand multimers (acquired von Willebrand dx) and this increases the risk for bleeding and resutls in identification of angiodysplasia (AVMs).

Bleeding improves after aortic valve replacement (seen as a systolic ejection murmur or a systolic cresendo-descresendo)

Question 24

connection between GI bleeding and ESRD pts?

Answer 24

see uremic platelet dysfunction in ESRD which increases bleeding risk and uncovers underlying angiodysplasia in pts.

Question 25

Do we ever repeat EGD after GI bleeding:

Answer 25

only indicated if _pt develops uncontrolled bleeding after EGD_ **repeat EGD after 4-6 weeks** is performed for _bleeding gastric ulcers_ (esp if symptoms persist or high concern for cancer. not _recommended for follow up with duodenal ulcers_ as cancer risk is low.

Question 26

Duodenal ulcer present in GI bleeding pt. Ulcer biopsied and found negative for H pylori. What to do next?

Answer 26

_repeat urea breath test_ and _stool antigen for H pylori as outpatient 2 week_s after PPI is completed. There is a **_high false negative rate for H pylori during acute GI bleeding, and with PPI (PO or IV), bismuth, and antibiotic use_**.

Question 27

aortoenteric fistula is a risk factors and presentation

Answer 27

**connection between aorta and GI tract** seen in distal duodenum and third portion because duodenum is fixed and anterior to aorta. seen with **previous aortic graft surgery** who presents with GI bleed. **"herald bleed"** _see brisk bleed with hypotension then stops spontaneously before having a massive GI bleed._ See fever, hypotension, and leukocytosis. Needs surgery but mortality is still \>50%

Question 28

imaging study to order for a suspected aortoenteric fistula

Answer 28

First imaging study to order is: CT abdomen with IV contrast because quick and non invasive.

Question 29

mesenteric angiogram detects bleeding RBC tagged scintography tags...

Answer 29

_bleeding rates as slow as 1 ml/min_ compared to 0.2 ml/min of a red blood cell scintigraphy. but not great for intermediate bleeding

Question 30

if patient has a lower GI Bleed what is to do next?

Answer 30

**_lower GI bleeding from:_** diverticulosis, colitis, hemorrhoids or post polypectomy bleeding. Lower GI bleeding stops wihtin 24 hours diagnostic test of choice: **_colonoscopy with oral bowel prep_.** This will be able to identify bleeding in 66% of pts

Question 31

RBC tagged scans or scintigraphy is useful for GI bleeding

Answer 31

**RBC tagged scans are for overt GI bleeding with unknown source.** They can _identify general areas_ but need to have repeat _endoscopy and angiography_ which can provide better localization and therapy.