L7 GI Bleeding and Iron Replacement Flashcards
Causes of Upper vs. Lower GI Bleed?
Upper:
- Peptic Ulcer Disease
- Esophageal Varices
- Mallory-Weis Tear
- Inflammatory Bowel
- Disease (Chrons)
- GAVE (Gastric Antral Vascular Ectasia)
Lower:
- Hemorrhoids
- Diverticular Bleed
- Inflammatory Bowel Disease
- Colonic Carcinoma
Indications for transfusion of red cells for a patient suspected of GI Bleed?
HB <_______ and _________ is indication for transfusion of red cells.
HB <________ in the setting of comorbidities (i.e., Heart Failure, Ischemic heart disease)
FBC: HB <7 g/dL and Symptomatic is indication for transfusion of red cells.
HB <8 g/dL in the setting of comorbidities (i.e., Heart Failure, Ischemic heart disease)
Investigations for Patient Suspected of GI Bleed?
- FBC: HB <7 g/dL, Lactate HIGH, Platelet count LOW
- Urea & Electrolytes + Bone profile: Disproportionate Urea:Creatinine Ratio= Risk of Hypocalcemia
- INR: look at synthetic markers of liver function (Albumin/ APTT)
Scoring systems used to predict mortality and re-bleed from GI Bleed?
Rockall Score: 2 or less associated with low risk of further bleeding and mortality post endoscopy
Blatchford Score: Score of 0 is associated with low risk of further bleeding. Done Pre endoscopy to stratify high risk patients who need admission for urgent endoscopy
What is the best measure of circulation for an unstable GI Bleed?
Heart Rate- if both hypotensive and tachycardic => pt. unstable and needs fluid resuscitation
Octaplas versus Octaplex?
Fresh Frozen Plasma (Octaplas): Albumin, immunoglobulins, coagulation factors (including fibrinogen), complement proteins, and protease inhibitors
Prothrombin Complex Concentrate (Octaplex): Vitamin K dependent clotting factors (X/VIII/VII/II)
- Good reversal agent of Warfarin and faster than Vitamin K.
- Promotes coagulation in the setting of a DOAC
What is a good reversal agent for Hermorgahe due to Warfarin/DOAC and is faster than Vitamin K?
Prothrombin Complex Concentrate (Octaplex)
Ideal Levels of Serum Fibrinogen?
> 1.5g/L
Treatment of Non-Variceal Upper/Lower GI bleeding?
1) Resuscitate
2) IV PPIs: reducing acid stabilizes clots
3) Endoscopy Treatment:
- Clips + adrenaline
- Thermal coagulation + adrenaline
- Fibrin or thrombin + adrenaline
Note: Adrenaline (vasoconstrictor that reduces blood flow to the area) should never be used as monotherapy- will wear off and start re-bleed
4) Endoscopic treatment fails and the patient is critically unstable?
- Open – surgical option to locate vessel and clip vascular supply
- Endovascular – Interventional Radiology guided procedure to coil active bleeding vessel
Treatment of Variceal Bleeds?
- IV PPI
- Terlipressin (Vasopressin Analogue) /Octreotide (Somatostatin Analogue)
- IV Antibiotics– Usually ceftriaxone
Indication/MOA/Side Effects of Terlipressin?
Vasopressin Analogue used to treat Variceal Bleeds
MOA: Preferentially vasoconstricts the splanchnic system via V1 and V2 receptor activation
Side Effects: Prolonged QT, Skin Necrosis, Myocardial Infarction
Indication/MOA/Side Effects of Octreotide?
Somatostatin Analogue used to treat Variceal Bleeds
MOA:
- Reduces splanchnic and gastrodudenal blood flow
- Inhibits acid secretion and pepsin release
- Reduces gastric motility*
Side Effects: GI Upset, Headache, Cholelithiasis (gall stones)
Investigations for Anemia?
Look for co-factors that are required for erythropoiesis:
- B12 + Folate
- EPO (created by kidney => end-stage renal failure has litle EPO)
- Iron (Ferritin and TSATs)
Significance of Ferritin?
Low/High Levels?
Protein in cells that stores Iron
- LOW = true iron deficiency
- HIGH = inflammation
Significant of Transferrin Saturations (TSATS)?
What do low levels indicate?
Protein that transports Iron in the blood
- LOW levels (<20%) indicate low Iron levels
