git bleeding Flashcards
upper gi bleeding location
bleeding above ligament of Treitz in the duodenum.
main cause of upper gi bleed
Peptic ulcer diseases (PUD); duodenal ulcer (25%), gastric ulcer (20%), gastritis (25%).
Reflux esophagitis.
Esophageal or gastric varices.
lower gi bleed loc
Refers to a bleeding below ligament of Treitz in the duodenum.
lower gi bleed in pts over 40 most likely what
colon cancer until proven otherwise.
what is the most common cause of lower gi bleed
diverticulosis
what are anatomic causes of lower gi bleed change of anatomical structure
hemorrhoids, anal fissures, meckels diverticulum, diverticulosis
vascular causes of lower gi bleed
angiodysplasia, ischemic colitis, radiation induced.
inflammatory causes of lower gi bleed
infectious colitis , (E. Histolytica, salmonella, shigella, C. difficle), IBD (mainly UC).
neoplastic causes of lower gi bleed
colorectal cancer & adenomatous polyps.
Symptoms of upper GI bleeding:
Hematemesis»_space; indicates moderate to severe bleeding that may be ongoing.
Coffee grounds emesis»_space; upper GI bleeding that has already oxidized by bleeding if they took any stomach acid, usually suggest lower rate of bleeding.
Melena» Black, tarry, liquid, foul-smelling stool. Suggest upper GI bleeding in 90% of cases (can be from small intestines or ascending colon in 10% of cases).
what is the reason of black tarry stool
Caused by degradation of Hb by colonic bacteria, presence of melena suggest that blood has remained in GIT for several hours.
Note that dark stools can also result from bismuth, iron, spinach, charcoal, licorice.
Symptoms of lower GI bleeding:
Hematochezia» Bright red blood per rectum that may or may not be mixed with stool.
Suggest lower GI bleeding (typically left colon or rectum), however, it may be present in large upper GI bleeding.
what is DD of lower gi bleed
DDx»_space; diverticulosis, arteriovenous malformations, hemorrhoids, & colon cancers.
investigation and diagnosis of vital signs in gi bleeding
Vital signs»_space; decreased BP, tachycardia, or postural change in BP or HR are signs of significant hemorrhage (however, vitals may be normal).
what lab tests would u order in gi bleeding
CBC:
Hb & Hct (>7-8 g/dl is acceptable in young healthy patients, >10 should be in elderly especially with cardiac diseases).
Electrolytes, BUN, Cr»_space; assess dehydration or renal dysfunction.
LFTs, bilirubin, albumin»_space; assess liver function.
Coagulation profile (platelet count, PT, PTT, INR)»_space; R/O bleeding disorders.
Blood grouping & Cross-matching»_space; for transfusion.
Stool guaiac for occult blood»_space; source of bleeding may be anywhere along GIT.
o If upper GI bleeding is suspected in stable patients:
Upper endoscopy within 24h.
Note that in hemodynamically unstable patients, a surgical and radiological team must be nearby because endoscopy can precipitate complications (e.g. perforation).
o If lower GI bleeding is suspected in stable patients
1) colonoscopy within 24h.
2) Bleeding scan (radionuclide scan)»_space; reveals bleeding even with low rate.
3) Arteriography»_space; localize the bleeding but should performed during active bleeding, mostly used in lower GI bleeding.
4) Exploratory laparotomy»_space; last resort.
In any case of massive GI bleeding hiw many units of blood do you order
order at least 4 units of blood to prevent fluid overload
what is the management of upper gi bleeding in PUD
Thermocoagulation therapy during or hemostatic clips combined with injected epinephrine (vasospasm) during upper endoscopy.
esophageal varices management
-IV octreotide & IV antibiotics (ciprofloxacin or ceftriaxone).
-Variceal ligation or endoscopic sclerotherapy.
-Ballon tamponade in refractory cases.
mallory weis syndrome management
Antiemetic agent (e.g. metoclopramide).
Endoscopic therapy with thermocoagulation, hemostatic clips, band ligation if active bleeding.
Diverticulosis management of lower gi bleed
Colonoscopy with thermocoagulation or epinephrine injection.
If bleeding not stopped, angiography to identify source of bleeding with vasoconstriction medication (e.g. vasopressin) or vessel embolization.
In refractory cases, segmental colectomy surgery.
hemorrhoids management
Dietary & lifestyle modifications, goal is to soften the stool (more water, food rich in fibers).
Analgesics creams, hydrocortisone suppositories, or Sitz-baths to relieve pain.
Internal hemorrhoids»_space; rubber band ligation.
External hemorrhoids»_space; hemorrhoidectomy.
what is the cause of esoohageal varices
Liver cirrhosis (portal HTN; lower esophageal veins are submucosal veins).
Schistosomiasis
Liver congestion (Budd-chiari syndrome).
Portal vein thrombosis.
what causes esophageal varices
Usually occur due to increased pressure in the portal vein — called portal hypertension.
Most commonly seen in liver cirrhosis (e.g., from alcohol, hepatitis B/C, fatty liver).
how do esophageal varices form
Liver disease causes scar tissue → blocks normal blood flow.
Blood backs up into the portal vein system (portal hypertension).
Blood finds alternative pathways to return to the heart — including esophageal veins.
These veins become engorged and form varices.
symptoms of esophageal varices
Symptoms»_space; massive hematemesis (fresh blood), exacerbation of hepatic encephalopathy.
tx and management of esophageal varices
1) Prevent bleeding (if varices are found but not bleeding):
-Beta-blockers (like propranolol or nadolol)
-Endoscopic band ligation
2) If actively bleeding:
-Emergency endoscopy with banding or sclerotherapy
-IV medications (e.g., octreotide)
-Balloon tamponade (in severe cases)
TIPS procedure (creates a new path for blood through the liver)
what controls bleeding in 80-90% of cases
Endoscopic sclerotherapy: Sclerosing substance is injected into varices during endoscopy.
what are prophylactic measures in esophageal varices
-Non-selective B-blockers (propranolol).
-Serial endoscopic evaluation (every 3 years).
