HYHO UGIB

Question 1

Why might anemia not be reflected in an initial CBC of acute blood loss?

Answer 1

Hemo-concentration of remaining circulating volume

Question 2

When might signs of hypovolemic shock occur?

Answer 2

30-40% volume loss

Inadequate blood circulation detected baroreceptor reflex => increased HR and sympathetic stimulation with vasoconstriction of nonessential orans

Question 3

Orthostatic hypotention may become evident at what volume depletion?

Answer 3

20-25%

Question 4

Tachycardia may become present with what volume depletion?

Answer 4

15%

Question 5

What is the single most life-threatening complication of portal HTN?

Answer 5

Bleeding from esophageal varices

Responsible for 1/3 of alld eaths in pts with cirrhosis

Question 6

What medications may alter pt’s stool and cause sx of GI bleed?

Answer 6

ASA and other NSAIDs (ibuprofen, naproxen sodium)

Antiplatelet agents (clopidogrel) and anticoagulants (warfarin)

Bismuth, iron - can color stool black

Question 7

When would you transfuse a pt with a GI bleed?

Answer 7

Hb <7 g/dL - low risk pts

Hb <9 g/dL - high risk pts

Question 8

What labs might you want to get on a pt with a GI bleed?

Answer 8

CBC with differential

Coagulation studies

Guiac testing of stool

Question 9

Initial resuscitation for UGIB

Answer 9

Evaluate hemodynamic stability

Obtain 2 large bore IV access (one for saline, one for blood products)

Consider central line placement

Crystalloid fluids if blood not available

Replace blood loss with blood products

Question 10

Indications for a central line

Answer 10

Inadequate peripheral venous access

Infusion of materials that would be damaging to peripheral veins (chemotherapy)

Question 11

Airway and circulation tx of UGIB

Answer 11

Consider intubation with prior supplemental O2

Fresh frozen plasma - INR >1.6

Keep platelets >50,000 if actively bleeding

Cross and match 2-4 units of blood PRBC

Question 12

What is endoscopy with sclerotherapy?

Answer 12

IV injection of sclerosant to irriate lining of fein and causes vein to close or use thrombotic agent to incite clot formation to stop bleeding

Controls acute bleeding in 80-85% of pts

Question 13

What is the TIPS procedure?

Answer 13

Transjugular intrahepatic portosystemic shunt - reduce portal systemic pressure shunting blood away from varices

Tract created b/w portal vein and hepatic vein with stent placement

Question 14

Surgical intervention of GI bleed when endoscopic and TIPS is not indicated

Answer 14

Surgical resection and vessel ligation - high chance of rebleed

Splenorenal shunt - splenic vein reattached to L renal vein

Question 15

What pharmacological agents may be used for peptic ulcer disease during initial endoscopy?

Answer 15

PPIs - omeprazole or esomeprazole 40 mg IV BID

Question 16

What is the use for octreotide (somatostatin) in suspected seophagogastric varices and/or cirrhosis?

Answer 16

May help shunt blood away from varices

Reduces secretions and loss of blody fluid

Question 17

What is the indication for use of fresh frozen plasma (FFP)?

Answer 17

Used to correct coagulation deficiency

Factor V and VII are available for up to 24 hours after thawing

Question 18

Is whole blood used for transfusions?

Answer 18

NO, EXCEPT IN RARE AND DIRE SITUATION

Question 19

Tx of choice for anemia

Answer 19

PRBC and crystalloid fluids

NOT WHOLE BLOOD

Question 20

What is the indication for use of platelet transfusion?

Answer 20

Stop active bleeding or prevent spontaneous bleeding in cases of thrombocytopenia

Question 21

Chapman’s point for stomach acidity

Answer 21

Left 5th ICS

Question 22

Chapmans point for stomach peristalsis

Answer 22

L 6th ICS

Question 23

GI viscerosomatic levels

Answer 23

T1-L2

(T5-9 specific to upper GI)

Question 24

In a GI complaint, which model would “Assess pt for excessive alcohol use and counsel for cessation” fall under?

Answer 24

Behavioral

Question 25

When should OMT be performed in a GI complaint?

Answer 25

After initial stabilization of pt and definitive tx of bleeding is identified

Rib raising, other gentle techniques

Question 26

Presence of both hematemesis and melena suggests presence of what?

Answer 26

Brisk bleeding

Question 27

What test would you use initially in a hemodynamically stable pt with hematemesis and/or melena?

Answer 27

Upper endoscopy

Colonoscopy if source not identified, small bowel evaluation if colonoscopy negative

Question 28

If severe bleeding continues to occur after colonoscopy, what tests might you want to do?

Answer 28

CT angiography/push enteroscopy => deep small bowel enteroscopy => angiography, meckel’s scan, laparoscopy/laparotomy