GI BLEEDING Flashcards
Most common cause of UGIB
Peptic ulcers
3 high risk findings of ulcer on endoscopy
- Active bleeding
- Nonbleeding visible vessel
- Adherent clot
High-dose, constant infusion of IV PPI sustain intragastric pH of:
> 6
Rebleeding percentage of peptic ulcers within the next year if no preventive strategies done
10-50%
3 main factors in ulcer pathogenesis:
- Helicobacter pylori
- NSAIDs
- Acid
Eradication of H. pylori decrease PUD rebleeding to:
< 5%
If necessary, what NSAID would you give in patient with GIB?
COX-2 selective plus a PPI
For GIB patients with CVD who takes low-dose aspirin for secondary prevention, when will you resume aspirin?
Restart aspirin ASAP after their bleeding episode (1-7 days)
For GIB patients who take aspirin for primary prevention, when will you resume aspirin?
No need to resume
If GIB is unrelated to H. pylori or NSAIDS, until when should you give PPI to patients?
Should remain on PPI therapy indefinitely because of rebleeding rates of 42% at 7 years
Most common bleeding site of Mallory-Weiss tear
Gastric side of the GEJ
Mallory-Weiss tear stops spontaneous in how many percent of cases?
80-90%
Recurrence rate of Mallory-Weiss Tear
0-10%
Poorer outcomes than other sources of UGIB
Esophageal varices
4 treatment for Esophageal varices
- Endoscopic ligation
- IV vasoactive medications
- Non-selective beta blockers
- TIPS
2 indications of TIPS in patient with BEV:
- For patients with persistent or recurrent bleeding despite endoscopic and medical therapy
- 1st 1-2 days of hospitalization for acute BEV in patients with advanced liver disease (Child-Pugh class C with score 10-13)
Endoscopically visualized breaks that are confined to the mucosa
Erosive disease
Cause of erosive esophagitis
GERD
Most important cause of gastric and duodenal erosions
NSAID use
Watermelon stomach
Gastric antral vascular ectasia
Aberrant vessel in mucosa bleeds from a pinpoint mucosal defect
Dieulafoy’s lesion
Hereditary hemorrhagic telangiectasias
Osler-Weber-Rendu
Prolapse of proximal stomach into esophagus with retching
Prolapse gastropathy
Bleeding from the bile duct
Hemobilia
Bleeding from pancreatic duct
Hemosucus pancreaticus
Percentage of obscure GIB that originate in the small intestine
~75%
3 most common causes of small-intestinal GIB in >40 years old:
- Vascular ectasias
- Neoplasm
- NSAID-induced erosions and ulcers
Most common cause of significant small intestinal GIB in children
Meckel diverticulum
Most common cause of LGIB
Hemorrhoids
Aside from hemorrhoids and anal fissures, what is the most common cause of LGIB?
Diverticulosis
Usual location of diverticulosis
Right colon
Bleeding stop spontaneously in how many percent of diverticulosis?
~80-90%
Rebleeding rate in diverticulosis
~15-40%
Without source of GIB identified on UGIE and colonoscopy
Obscure GIB
Bleeding vascular ectasias and aortic stenosis
Heyde’s syndrome
2 most common causes of significant colonic GIB in children and adolescents
- Inflammatory bowel disease
* Juvenile polyps
Measurement of these 2 is the best way to initially assess a patient with GIB
Heart rate and BP
It may take up to how many hours for Hgb to fall in acute GIB
72 hrs
Hemoglobin does not fall immediately in acute GIB. Why?
Proportionate reductions in plasma and red cell volumes
Transfusion is recommended once Hgb is _____. And what do you call this strategy?
- ≤ 7 g/dL
* Restrictive transfusion strategy
In melena, blood has been present in the GIT for how many hours?
≥ 14 h or as long as 3-5 days
Aside from melena, what are 2 other clues of UGIB in differentiating with LGIB?
- Hyperactive bowel sounds
* Elevated BUN
3 baseline characteristics predictive of rebleeding and death in UGIB:
- Hemodynamic compromise
- Increasing age
- Comorbidities
Promotility agent to improve visualization? Dose?
Erythromycin 250 mg IV ~ 30 min before endoscopy
In what subset of UGIB patients will you give antibiotics? And what antibiotics?
- Cirrhotic
* Quinolone or ceftraixone
May improve control of bleeding in cirrhotics with UGIB in the 1st 12 h after presentation
IV vasoactive medications
When should you perform upper endoscopy? In high-risk patients?
- Within 24 hrs
* Within 12 hrs
BUN scoring in Glasgow- Blatchford score
- 18.2 to <22.4 = 2
- 22.4 to <28.0 = 3
- 28.0 to <70.0 = 4
- ≥ 70 = 6
Hemoglobin scoring in Glasgow- Blatchford score (men and women)
- 12 to <13 (men) = 1
- 10 to <12 (women) = 1
- 10 to <12 (men = 3
- <10 = 6
SBP scoring in Glasgow- Blatchford score
- 100-109 = 1
- 90-99 = 2
- <90 = 3
Heart rate scoring in Glasgow- Blatchford score
≥ 100 = 1
Scoring of other markers in Glasgow- Blatchford score
- Melena = 1
- Syncope = 2
- Hepatic disease = 2
- Cardiac failure = 2
In patients with hematochezia + hemodynamic instability, what procedure should you do first?
UGIE to rule out UGIB
Procedure of choice for LGIB, unless bleeding is too massive
Colonoscopy
Procedure for massive LGIB
Angiography
Procedure for LGIB in patients < 40 years old with minor bleeding
Sigmoidoscopy
Initial test in patients with massive bleeding from the small intestine
Angiography
Next step in patients with GIB with negative UGIE or colonoscopy
- Second-look procedure – repeat upper and lower endoscopy
* May also do push enteroscopy
Inspect the entire duodenum and proximal jejunum with a pediatric colonoscope
Push enteroscopy
If second-look procedure in GIB patient is negative, what is the next step?
Video capsule endoscopy (may also do push enteroscopy)
May be used initially instead of video capsule in patients with possible small bowel narrowing
CT enterography
If capsule endoscopy is negative, what is the next step?
Observe or do further testing with deep enteroscopy
Next step if you have a positive FOBT:
Do colonoscopy
