L7 GI Bleeding and Iron Replacement Flashcards

1
Q

Causes of Upper vs. Lower GI Bleed?

A

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
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2
Q

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)

A

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)

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3
Q

Investigations for Patient Suspected of GI Bleed?

A
  • 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)
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4
Q

Scoring systems used to predict mortality and re-bleed from GI Bleed?

A

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

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5
Q

What is the best measure of circulation for an unstable GI Bleed?

A

Heart Rate- if both hypotensive and tachycardic => pt. unstable and needs fluid resuscitation

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6
Q

Octaplas versus Octaplex?

A

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
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7
Q

What is a good reversal agent for Hermorgahe due to Warfarin/DOAC and is faster than Vitamin K?

A

Prothrombin Complex Concentrate (Octaplex)

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8
Q

Ideal Levels of Serum Fibrinogen?

A

> 1.5g/L

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9
Q

Treatment of Non-Variceal Upper/Lower GI bleeding?

A

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
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10
Q

Treatment of Variceal Bleeds?

A
  • IV PPI
  • Terlipressin (Vasopressin Analogue) /Octreotide (Somatostatin Analogue)
  • IV Antibiotics– Usually ceftriaxone
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11
Q

Indication/MOA/Side Effects of Terlipressin?

A

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

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12
Q

Indication/MOA/Side Effects of Octreotide?

A

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)

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13
Q

Investigations for Anemia?

A

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)
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14
Q

Significance of Ferritin?

Low/High Levels?

A

Protein in cells that stores Iron

  • LOW = true iron deficiency
  • HIGH = inflammation
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15
Q

Significant of Transferrin Saturations (TSATS)?

What do low levels indicate?

A

Protein that transports Iron in the blood

  • LOW levels (<20%) indicate low Iron levels
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16
Q

What Does Total Iron Binding Capacity (TIBC) Measure?

A

Indirect measurement of the amount of iron will bind to transferrin

17
Q

First-Line Therapy for Anemia? Side Effects?

A

Oral Iron (Ferrous Fe2+ formulations have better bioavailability)

GI Upset common (IV Often Favored)

Black Stools from Oral Iron Therapy can be confused for melena

18
Q

IV Iron Therapy Formulations/Indications/Side Effects?

A

Ferric Carboxymaltose (Ferrinject)
Iron Sucrose (Venofer)

Indication: Provided if oral failed: more effective than oral esp. in heart failure, CKD, IBD and malignancy

Side Effects:

  • Anaphylaxis
  • Hypophosphatemia
  • Hypersensitivity: ratch, dyspnea