GI Concerns Flashcards
Difference between upper GI bleeds and lower sx/signs
Upper GI: Hemoptysis, melena (as long as not massive bleed), coffee grounds hematemesis
Lower GI: hematochezia, bright red blood rectal bleed
Indications for investigation of GI and bleeds
Age + risk factors for CA, showing signs of iron deficiency, if they are not stable, other medical conditions (IBD, GERD, ulcers, renal or liver disease), chronic medications (NSAIDS, anti-platelet/ anti-coagulation)
Types of investigations for lower GI bleeds
Rectal exam/ and abdominal
Full set of vitals, look at skin for other signs of disease
Lab works - inflammatory markers, hemoglobin, iron
Colonoscopy
Investigations for upper GI bleed
Lab work + (Ab test for H.pylori), gastroscope, breath urea test for H.Pylori
Abdominal exam, consider HEENT
Risk factors for colorectal CA
Age over 50, family hx (Lynch syndrome), smoking, high red meat/ processed meat diet, alcohol, DM, colonic polyps and IBD
What causes portal hypertension and esophageal varices
Damage to the liver, most commonly cirrhosis, causes decreased flow of blood from the GI through the liver, leads to back up and increased pressure. Blood is then shunted inappropriately through collateral blood supply - leading to varicosities
Gastroesophageal collateral = esophageal varices
Superior rectal vein = hemorrhoids
Round ligament remnant = caput medusae
What causes peptic ulcers
Can be related to several factors: is caused when acid and pepsin break through the mucosa of the stomach
- H.Pylori
- Alcohol use
- NSAIDS
- secondary to malignancy
- Zollinger-Ellison syndrome - too much gastric acid
Why do NSAIDS cause GI bleeds
Inhibits COX 1 which makes prostaglandins, which help produce bicarbonate and mucus and reduce gastric acid and pepsin and maintain adequate blood flow to stomach
What increases the likelihood of a person having another GI bleed?
Continued NSAID use/ added anti-coagulants or anti-platelets
Failure to modify precipitating lifestyle factors (straining with hemorrhoids, diet, alcohol use).
Age greater than 65, poor overall health, comorbidities, low hemoglobin, continued melena/ fresh blood, evaluated urea, creatinine, ALT
On endoscopy - active bleeding, visible vessels, large ulcer (>2cm), posterior ulcer
Can use Blatchford score or Rockall score
Tx for hemodynamically unstable patient
Fluids +++, cross and type to prepare for transfusion
Hbg less than 70 transfuse, locate source of bleeding and try to stop it (POCUS, rectal exam, bladder scan) - for esophageal varices endoscopic ligation, esophageal catheter/ intubation
Consider transexmic acid
IV octreotide - to reduce pressure for esophageal varices
Current guidelines for colon CA screening
Age greater than 50 to 74 - FIT every 2 years or colonoscopy every 10
If family hx - start at 10 years earlier than family member DX, with colonoscopy every 5 yrs
Recommendations for PPI use
PPI are only indicated for less than 8 weeks, try to de-prescribe after 4 - only indicated for dual anti-platelet therapy, prior GI bleed, ongoing NSAID, Barrett’s esophagus or ongoing hyper secretions of gastric acid
Long term use - try to take off or reduce for part of the year, consider Mg supplementations and Vit C with iron if needed, Ca++ supplementation if needed.
Risks of long-term PPI use
- Enteric infections (C. difficile, Campylobacter, Salmonella)
- Fractures
- Pneumonia (hospital or community acquired)
- Spontaneous Bacterial Peritonitis in cirrhosis patients
- Hypomagnesemia
- Acute Interstitial Nephritis
- Vitamin B12 deficiency
Organisms causing bloody diarrhea
Shigella
Salmonella
Campylobacter jejuni
E.coli ( O157:H7)
Meckel’s Diverticulum - rule of 2s?
2% of people, under 2, 2 ft from the illeocecal valve
N/V/ painless rectal bleed
