Lecture 10: GI Bleeding Flashcards
What to check to see if a GI bleed is an emergency?
Vitals (hypotension/tachycardia) = hypovolemia
Why do patients with a GI bleed get an elevated BUN
Hypovolemia and absorbed blood protein
NG lavage tube…reliable to test for bleeds?
Nope: can get false negatives and positives
History suggesting GI bleed/causes (7)
Aspirin/NSAID, ulcer disease, liver disease (varices), preceding retching (MW tear), GERD (esophagitis), aorta-enteric fistula (aortic aneurysm surgery), cancer
Two types of GI bleeds
Overt: hematemesis, melena, hematochezia; Occult: microscopic blood in stool over weeks to months
Occult bleeding leads to..
Anemia and iron deficiency
What is hematochezia
Red/maroon blood in stool associated with frequent BM
Things that suggest upper bleed
Hematemasis, coffee grounds, melena
Thing that suggests lower bleed
Hematochezia (or MASSIVE upper bleed)
Why do we scope?
Diagnose, treat, prognosis
Peptic ulcer accounts for % of upper GI bleeds; etiology, % stop spontaneously
50%; H pylori or NSAIDs; 80%
GI Bleed: what do we do?
IV fluid, IV PPI, urget endoscopy (dx, tx, prognosis), surgery (failure of medical therapy), always look for H pylori
Once again, what do we always do with gastric ulcers?
Look for H pylori
Gastritis: % of upper GI bleeds, life threatening? Etiology?
15%, usually not life threatening, NSAIDs, alcoholism, stress gastritis (serious stress), inhibit acid and avoid NSAIDs
Neoplasm: what kind of bleeding?
Chronic bleeding (occult)
Two esophageal causes of GI bleeds
Mallory Weiss tear and esophageal varices
Dieulafoy lesion
Large caliber artery in stomach with significant bleeding, hard to find
GAVE
Watermelon stomach, dilated mucosal vessels
Aorto-Enteric fistula. Common presentation?
Massive bleeding in pt with prior aortic graft that erodes into duodenum; herald bleed (massive bleed that then stops)
Cameron lesion. Type of bleeding?
Erosions or ulcerations that occur within a hiatal hernia; typically occult
Endoscopic therapy techniques
Injection (epi, ST but helps you visualize area), hemostatic therapy (cauterizing), band ligation (common for esophageal varices), clips
Lower GI bleeding presents with what? Common course?
Hematochezia, frequently stops spontaneously (intermittent)
T/F: Lower GI bleeding is typically chronic
True
Common causes of lower GI bleeding (4)
Hemorrhoid (painless, blood on tissue), anal fissure (pain during stool passage), colitis (urgency, tenesmus, pain, diarrhea), polyp/cancer (blood mixed with stool)
Two causes of acute hemodynamically significant lower GI bleeds
- Diverticulosis and 2. Arteriovenous malformations (AVMs)
Most common causes of hemorrhoids (2)
Pregnancy and constipation
Anal fissure presentaton, tx
Red blood with BM, tearing/burning pain, blood in toilet bowel, tx = topical medications
T/F: It’s always easy to find bleeding diverticulum
False: pts often have more than one diverticulum and the bleeding can be sporadic
Colitis: presentation
Blood/cramping either acute (ischemia, infectious) or chronic (IBD, Crohn’s)
Can colon polyp’s bleed? What percent of polyps and cancer bleeds are associated with acute lower GI bleeds?
Yes (also after polyp removal); 5%
How to evaluate lower GI bleeding?
Endoscopy (colonoscopy) or nuclear scan
Describe nuclear scan
Labeled RBC scan, and can be repeated within 24 hours if bleeding begins again
Describe angiogram
Catheter in femoral artery with contrast to see where the leak is, then you can give therapy to help bleeding (however, requires active bleeding and is invasive w/ complications)
What % of bleeding is not identified by upper or lower endoscopy? What is it called?
5%, “obscure” GI bleeding
Causes of obscure GI bleeding
Small intestinal: Vascular (AVM), neoplastic, inflammatory diseases, Meckel’s diverticulum; biliary; pancreatic
Why does Meckel’s diverticulum produce bleeding? Painful?
Heterotopic gastric mucosa –> acid –> ulceration –> bleeding; non-painful bleeding
How to dx Meckel’s?
Meckel’s scan (nuclear) that looks for parietal cells
Patent profile for Meckel’s
Young males, obscure bleeding
What is a push entroscopy? What is a surgical option? What is a non-invasive option?
Endoscopy of the small intestine, can reach the mid jejunum (4 ft); intra-operative endoscopy (very invasive); capsule endoscopy (camera)
If you find something with a capsule endoscopy, what do you do next?
Double-balloon enteroscopy
