HYHO UGIB

Question 1

What landmark differentiates an upper GI bleed from a lower GI bleed?

Answer 1

Ligament of Treitz = the suspensory ligament of the duodenum

Question 2

Patient presentation associated with UGIB

Answer 2

1. Hematemesis = vomiting blood
2. Coffee-ground emesis
3. Melena = dark, tarry stools
4. Anemia
5. Hypovolemic shock: low circulating blood volume triggers baroreceptors –> inc HR, inc sympathetic stimulation, blood directed away from skin, skeletal ms. –> pt appears cold, clammy, vasoconstricted

Question 3

What specific cause of an UGIB is suggested by the following symptoms:

upper abdominal pain

Answer 3

Peptic ulcer

Question 4

What specific cause of an UGIB is suggested by the following symptoms:

Odynophagia, gastroesophageal reflux, dysphagia

Answer 4

Esophageal ulcer

Question 5

What specific cause of an UGIB is suggested by the following symptoms:

emesis, retching, or coughing prior to hematemesis

Answer 5

Mallory-Weiss tear

Question 6

What specific cause of an UGIB is suggested by the following symptoms:

jaundice, abdominal distention (ascites)

Answer 6

Variceal hemorrhage or portal hypertensive gastropathy

** bleeding from esophagogastric varcies is the single most life-threatening complication of portal HTN

Question 7

What specific cause of an UGIB is suggested by the following symptoms:

dysphagia, early satiety, involuntary weight loss, cachexia

Answer 7

Malignancy

Question 8

Common medications that cause peptic ulcer formation

Answer 8

• • aspirin

- - other NSAIDs (ibuprofen, naproxen, sodium, etc.)

Question 9

Common medications that promote bleeding

Answer 9

• • antiplatelt agents (clopidogrel)

- - anticoagulants (warfarin)

Question 10

Medications that can alter clinical presentation (make you mistakenly think there is a GI bleed)

Answer 10

• • Bismuth (pepto-bismol)
• • iron

both can turn stool black

Question 11

Key physical signs to look for when suspecting UGIB and what these signs indicate

Answer 11

1. Vital signs - may indicate hemodynamic compromise, signs of shock
2. Confusion - may indicate lack of blood flow/oxygen to brain
3. Peripheral vasoconstriction - look for cool extremities, may indicate cyanosis
4. Signs of liver disease - look for jaundice, ascites, caput medusa

Question 12

What labs should you order when suspecting a UGIB

Answer 12

1. CBC w/differential
2. Coagulation studies (PT/INR), liver enzymes (AST, ALT), albumin, BUN, and creatinine
3. Guaiac testing of stool - evaluates for blood in stool

Question 13

What might a CBC w/diff tell you

Answer 13

• • low platelets = may hinder coagulation
• • transfuse if hemaglobin is < 7g/dL (in low risk patient), or below 9 g/dL (in high risk patient = the elderly, those with heart disease)

Question 14

Four main intervention steps to remember for managing UGIB

Answer 14

1. Initial resuscitation – focus on circulating volume
2. Airway & Circulation – Intubate early with back-up and lots of suction
3. Consults – GI, Radiology and/or surgery early for definitive diagnosis and treatment
4. Give antibiotics

Question 15

What spinal levels correspond to the GI system in general, which correspond to the upper GI specifically?

Answer 15

General GI: T1 - L2

Upper GI specifically: T5 - T9

Question 16

Parasympathetics for upper GI

Answer 16

Vagus n. (OA and AA joints)

Question 17

Chapman points for stomach acidity

Answer 17

Left 5th ICS

Question 18

Chapman pint for stomach peristalsis

Answer 18

Left 6th ICS

Question 19

The following are components of which category in the 5 model approach:

• • Volume resuscitation using crystalloids; evaluate for transfusion needs
• • Consider rib raising once pt is stable
• • Address C3 - C5 phrenic n. to diaphragm fascia to improve excursion and thus pressure gradients to thoracic cage and associated lymph movement
• • Indirect MFR to thoracolumbar diaphragm

Answer 19

Respiratory-Circulatory

Question 20

The following are components of which category in the 5 model approach:

• • Endoscopy or surgery to address source of bleeding
• • Treat with PPI to facilitate healing of intestinal lining
• • Eliminate NSAIDs
• • Address nutritional needs (alcoholics commonly have deficits of B12 or folate)

Answer 20

Metabolic Energy

Question 21

The following are components of which category in the 5 model approach:

– Address somatic dysfunctions, OA/AA, throacic spine; in the case of upper GI bleed, T5 - T9 for upper intestine

Answer 21

Biomechanical

Question 22

The following are components of which category in the 5 model approach:

– Identify and treat viscerosomatic findings, chapman reflex points, and celiac ganglion

Answer 22

Neurologic

Question 23

The following are components of which category in the 5 model approach:

– Assess patient for excessive alochol use and counsel for cessation

Answer 23

Behavioral