GIB Flashcards
prevalence
Males: Females = 2:1
more alcoholic men
UGI bleeding
30yo alcoholics –> varices
duodenal ulcers–> old rich people
Tear in the esophagus after you vomit is known as
Mallory-Weiss
mortality of GI bleeds
3-14%
8%
acute GI bleed continouse %
4/5 are fine
What labs
CBC-
INR
CMP
CBC, why do we get it and what are we looking at
a. Hemoglobin –> concentration per volume; even if you lose half your blood volume, your hemoglobin will be the same
why can you see normal hemoglobin
—> concentration per volume; even if you lose half your blood volume, your hemoglobin will be the same
the ratio of the volume of red blood cells to the total volume of blood.
Hematocrit
why do you see changes with chronic bleeding
c. If you have been chronically bleeding you will hold onto WATER (not blood or cells)
who dies from a GI bleed
- Shock, red blood; low BP
- Cause of bleeding (varices or cancer very bad)
a. The cause does effect your risk
i. Cirrhotic –> poor prognosis - Comorbid disease
- Older age
- Onset in hospital
- Recurrent bleeding
why do you see varicies in alcoholics
Increase in portal vein you get esophageal and stomach varices
how does an NG tube work
o Withdrawal of blood is diagnostic for UGIB
oInsight as to acuity/ severity of bleed (coffee grounds, BRB, negative)
oAllows for clearance of stomach which can:
- Reduce risk of aspiration
- Clears the view for EGD
o”Easy” to place with little risk of complication
cons of a NG tube
o Uncomfortable
o Potential false negative if post-pyloric source
o Risk for sinusitis or bronchus placement
black stool usually indicative of
melena (bleeding is higher up; upper GIB –> blood gets acted on by bacteria in your colon which changes its color)
why would you see dark stool with a lower gib
Cecum is the top of the colon and cancer here could cause bleeding that takes a while and is seen and black
why would you see a red bleed with UGIB
has to be a HUGE volume of blood if its UGIB
White stool
very very rare acholic stool (bile obstruction from pancreatic cancer)
how much blood do you need for black stool
Only 50-100cc blood needed
why is stool black
oxidation from bacteria
Bright red blood per rectum AND blood in stomach
Bright red blood per rectum AND blood in stomach = that is a BAD UGIB
If clear stomach and black stool
you will do reasonably well; were previously bleeding
coffee grounds
oxidized blood
If I drop an NG tube in your stomach, and there is bright red blood
- that means you are actively bleeding = that is VERY BAD
a. Most common cause of UGIB
: PUD
4 major risk factors for GIB
major Risk Factors
i. NSAIDs/ Aspirin
ii. Helicobacter pylori infection
iii. Physiologic Stress (i.e. hospitalized patients with life threatening illness)
iv. Gastric Acid
Bleeding vessel is associated with what mortality
Bleeding vessel is associated with >10% mortality
most common PU that bleeds?
b. Gastric > Duodenal
most common stigmata with PUD
clean base
stigmats seen with peptic ulcers
clean base flat spot adherent NBVV Active bleed
NBVV stands for
i. NBVV –> nonbleeding visible vessel
chance of rebleeding with NBVV
Pts w/ NBVV has a 43% rebleeding risk
chance of bleeding again with active bleed
55
chance of rebleed with therapeutic endoscopy
20%
what are the benefits to endoscopic therapy
20-40% early discharge
with loq risk
money saving
decreases rebleed by 50%
effect of pH on platelet aggregation
a. Reduced pH is associated with reduced platelet aggregation
b. Clotting is pH dependent
i. Blood doesn’t like to clot at a pH of 1
1. Pepsin doesn’t work
2. Platelets don’t aggregate
acid and it’s relationship to ulceration
acid causes ulcers
how to control acid and minimize bleeding
PPIs reduce rebleeding and need for surgery, but do not effect mortality compared to control
h pylori eradication
stop NSAIDS
how to minimize bleeding for low risk pt
stop taking NSAIDS and eradicate H pylori
how to minimize bleeding risk in a pt that is high risk
endoscopic tx
PPI: prevention of stress related bleeding
stop NSAIDS and eradicate H pylori
maybe surgery
what is a low risk bleeding pt look like (endoscopy assessment)
clean base or flat spot
or adherent clot
what does a high risk pt look like (endoscopy assessment)
active bleed or visible vessel
what does initial assessment look like for a pt with a bleed (not endoscopy)
age greater than 60 comorbidity low bp red blood shock ongoing bleed prolonged cirrhosis erratic mental status
how many alcoholic cirrhosis or viral hepatitis pts get varices
what is the mortality rate for these pts
1/4 of pts with
and mortality in 30%
pressures are higher in the hepatic vein and back up
tx for varices
banding
and octreotide adjunct for suspected varices
octreotide
analog of somatostatin (in your body)
synthesized protein that lowers portal pressure and lower bleeding
it’s an adjunct to scoping and banding
why are lower GI bleeds so difficult to find
very hard to stop diverticula bleeding because the cause is rarely identified
to stream like an ulcer
AVM
arterial venous malformation
talangectasia
can be congenital
can be caused by radiation
tx for lower GI bleed
no pharmocological tx
surgery
angiography (contrast) stop blood vessle through embolism
but usually resolves on its own
occult bleeding tests
FOBT
used to do GAUIAC but that can detect blood in digested food
but now we do the FIT test (only measures human hemoglobin)
if you have a positive blood occult test what next
colonoscopy
but most are just indicative of hemorrhoids
how could we assess bleeding in the small bowel
might want to use a capsule
WCE
small bowel bleeding or crohns
initial management
i. 2 large bore IVs
ii. Bolus NS
iii. Type and Cross blood
iv. Labs
difference between hematocrit and hemoglobin
i.
Hematocrit is calculated from hemoglobin
This is a % of your blood that is blood cells
% of pt with rebleeding in order from highest occurance and mortality to lowest
varices gastric cancer peptic ulcers gastric erosions mallory weiss
what % of melena is from UGI
70-90% melena is from an UGI source
MCC of LGIB
diverticulitis then malignancy ischemic colitis IBD hemorrhoids post polypectomy
how many pts are controlled with LGIB treatment
no pharmological
therapeutic endocscopy only treats 20-30%
Tx for pt at high risk for UGIB
heal ulcer with PPI
h pylori eradication
stop NSAID
