GI BLEEDS

Question 1

NSAIDS and Stress (physiological) can cause what type of bleed?

Answer 1

Gastric/duodenal

Question 2

Cirrhosis can cause what type of bleed(s)?

Answer 2

Esophageal varices & Portal Hypertensive gastropathy

Question 3

Candida and ETOH can cause what type of bleed?

Answer 3

Severe/erosive esophagitis, gastritis, and duodenitis

Question 4

Repetitive retching can cause what type of bleed?

Answer 4

Mallory-weiss tear

Question 5

If you see severe belly pain with involuntary guarding or rebound tenderness – what should you consider?

Answer 5

Perforation

Question 6

What is hematemesis?

Answer 6

Frank blood (vigorous active bleeding)

Coffee ground (slower more limited bleeding)

Question 7

What is melena?

Answer 7

Black tarry stool (seen in various bleeds and can show up with less than 50cc of blood)

Question 8

What is hematochezia?

Answer 8

bright red to maroon

Usually seen in lower GI bleed

Question 9

What if hematochezia + hypotension indicate?

Answer 9

A MASSIVE UPPER BLEED!!

Question 10

What is the progression of a patient going down the tubes with a GI bleed?

Answer 10

Stable vitals → Tachycardia with normal BP → Orthostatic hypotension (indicates 15% total volume loss) → Supine Hypotension (indicates 40% total volume loss)

Question 11

About how much blood in the human body?

Answer 11

5L

Question 12

What is the maximum survivable blood loss?

Answer 12

About 40%

AKA when they have supine hypotension – be VERY concerned

Question 13

What testing should everyone get with a GI bleed?

Answer 13

CBC (H&H and Platelets)

CMP (BUN and Liver enzymes)

Coag panel (anticoag)

Type and Cross (for anticipated transfusion

Question 14

What would the liver enzymes tell you?

Answer 14

Underlying liver problem

Question 15

What would a BUN tell you?

Answer 15

Often associated with an upper bleed

If greater than 20:1

Question 16

How often should we repeat an H&H?

Answer 16

Every 4-6 hours

Question 17

If patient reports a little bit of witness GI blood loss, but normal vitals, and slight tachycardia – what do you do?

Answer 17

GI consult, IV PPI, Maybe transfusion, Upper endoscopy

Question 18

What meds do we use for PPI treatment?

Answer 18

Olmeprazole = outpatient
Protonics = inpatient

Question 19

If a patient has frank red blood seen by his wife and again by the nurses – what do we do?

Answer 19

Get vitals!!/Cardiac monitor/Frequent BP checks
Establish 2 large bore IV sites
Give O2
Bolus IVF (Normal saline)
Prep for transfusion
IV PPI, octreotide (variceal bleed), reversal agents if anticoagulated
CALL!!! Urgent endoscopy, general surgery, and intensivist

Question 20

What does an H&H tell you?

Answer 20

Is my patient still bleeding? Is the patient going down the tubes?

Question 21

A drop in H&H by ___ is considered significant

Answer 21

1 gram drop

*Always remember hemodilution

Question 22

An upper endoscopy is the same as what?

Answer 22

EGD

Question 23

What do we need for a variceal bleed?

Answer 23

Octreotide, Endoscopy, TIPS procedure (transjugular intrahepatic portosystemic shunt, after 3 episodes)

Question 24

If a patient has a GI bleed and they’re on an anticoagulation (Coumadin) – what do we do?

Answer 24

STOP Coumadin

Rank severity

Call the Pharm D

Reverse!! → Vit K IV or Kcentra + Vit K

Question 25

What if your patient with a GI bleed is on a novel anticoagulant?

Answer 25

Call the pharm D → we don’t really know how to reverse it

Question 26

What are some common causes of lower GI Bleeds?

Answer 26

Hemorrhoids, diverticulitis, colitis, or colo/rectal CA

Question 27

How do we approach a lower GI bleed?

Answer 27

Rule-out an upper GI bleed THEN do a colonoscopy

Question 28

How do we manage a lower GI bleed?

Answer 28

blood loss managed in the same way as an upper GI bleed

Question 29

If a nurse calls you because a patient just pooped bright red blood and his BP 90/45 (which is much lower than before)?

Answer 29

Kick the system into HIGH GEAR! (the same system we talked about before)

Question 30

What if your patient with BRB in his poop with decreased BP, you realized he’s on Coumadin – what do you do?

Answer 30

Stop Coumadin → Call Pharm D → Give Vit K and Kcentra → notify all consultants