GI bleeding Flashcards
occult GI bleeding suggestive symptoms
symptoms of anemia, iron deficiency or microcytosis, heme positive stools
what is occult GI bleeding defined as
positive fecal occult blood test with or without Fe deficiency anemia in absence of visible blood loss
what causes occult GI bleeding?
malignancy, peptic ulcers, vascular malformations, diverticula, inflammatory bowel dx
what is next step in evaluation of occult GI bleed if EGD and colonscopy are negative?
need a to look at small bowel with a wireless capsule endoscopy
adult meckel’s diverticulum
asymptomatic but can have painless GI bleeding in pts <2 yrs rare in pts >40 yrs.
when to order a radionuclide scan?
detects over GI bleeding and bleeding must be fairly rapid (0.1-0.5ml/min)
when to order a enteroclysis or double contrast study with injection barium and air into a tube that is passed through the small bowel
low diagnostic yield <20% and only performed if cannot do a capsule endoscopy
GI bleed algorithm
Transfusion goal is
Hgb>7
transfusion goal if they have possible variceal bleeding
Keep INR<3 for EGD and Plt >50 and can get FFP when appropriate
Severe anemia such as those with unstable coronary artery disease goal
Hgb >9 esp if they have unstable angina or ACS
Mallory Weiss tear is
upper GI mucosal tear with sudden increase in intraabdominal pressure from forceful retching
can cause subcuosal arterial or venule plexus bleeding.
Pts typically present with epigastric pain radiating to back and hematemesis after extended nausea and vomiting.
Mallory weiss tear
= bleeding is self limited to 24-48 hrs of bleeding.
How to evaluate and diagnose MW tear
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.
threshold for safely doing urgent EGD based on INR
INR <1.5-2.5
Initial management of upper GI bleed:
(management based on EGD results)
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
High risk ulcers in GI bleed are important because
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.
What is the risk for rebleeding in a patient with GI bleed who gets EGD?
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
who goes to the ICU for GI bleed?
When do we start octreotide?
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.
after treatment with EGD for a high risk ulcer what should GI bleed patients get?
clear liquid diet for 2 days
continued high dose IV PPI For 3 days to minimize bleeding risks
Causes of lower GI bleeding include:
anatomical conditions - diverticulosis
vascular causes - arteriovenous malformations AVMs
inflammatory dx (inflammatory bowel disease)
malignancy.
intestinal angiodysplasia or AVM is seen in which people?
also how does it cause issues?
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
what is the connection between GI bleeds and AVMs and aortic stenosis?
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)
connection between GI bleeding and ESRD pts?
see uremic platelet dysfunction in ESRD which increases bleeding risk and uncovers underlying angiodysplasia in pts.
Do we ever repeat EGD after GI bleeding:
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.
Duodenal ulcer present in GI bleeding pt. Ulcer biopsied and found negative for H pylori. What to do next?
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.
aortoenteric fistula is a
risk factors and presentation
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%
imaging study to order for a suspected aortoenteric fistula
First imaging study to order is: CT abdomen with IV contrast because quick and non invasive.
mesenteric angiogram detects bleeding
RBC tagged scintography tags…
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
if patient has a lower GI Bleed what is to do next?
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
RBC tagged scans or scintigraphy is useful for GI bleeding
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.
