Lecture 10: GI Bleeding

Question 1

What to check to see if a GI bleed is an emergency?

Answer 1

Vitals (hypotension/tachycardia) = hypovolemia

Question 2

Why do patients with a GI bleed get an elevated BUN

Answer 2

Hypovolemia and absorbed blood protein

Question 3

NG lavage tube…reliable to test for bleeds?

Answer 3

Nope: can get false negatives and positives

Question 4

History suggesting GI bleed/causes (7)

Answer 4

Aspirin/NSAID, ulcer disease, liver disease (varices), preceding retching (MW tear), GERD (esophagitis), aorta-enteric fistula (aortic aneurysm surgery), cancer

Question 5

Two types of GI bleeds

Answer 5

Overt: hematemesis, melena, hematochezia; Occult: microscopic blood in stool over weeks to months

Question 6

Occult bleeding leads to..

Answer 6

Anemia and iron deficiency

Question 7

What is hematochezia

Answer 7

Red/maroon blood in stool associated with frequent BM

Question 8

Things that suggest upper bleed

Answer 8

Hematemasis, coffee grounds, melena

Question 9

Thing that suggests lower bleed

Answer 9

Hematochezia (or MASSIVE upper bleed)

Question 10

Why do we scope?

Answer 10

Diagnose, treat, prognosis

Question 11

Peptic ulcer accounts for % of upper GI bleeds; etiology, % stop spontaneously

Answer 11

50%; H pylori or NSAIDs; 80%

Question 12

GI Bleed: what do we do?

Answer 12

IV fluid, IV PPI, urget endoscopy (dx, tx, prognosis), surgery (failure of medical therapy), always look for H pylori

Question 13

Once again, what do we always do with gastric ulcers?

Answer 13

Look for H pylori

Question 14

Gastritis: % of upper GI bleeds, life threatening? Etiology?

Answer 14

15%, usually not life threatening, NSAIDs, alcoholism, stress gastritis (serious stress), inhibit acid and avoid NSAIDs

Question 15

Neoplasm: what kind of bleeding?

Answer 15

Chronic bleeding (occult)

Question 16

Two esophageal causes of GI bleeds

Answer 16

Mallory Weiss tear and esophageal varices

Question 17

Dieulafoy lesion

Answer 17

Large caliber artery in stomach with significant bleeding, hard to find

Question 18

GAVE

Answer 18

Watermelon stomach, dilated mucosal vessels

Question 19

Aorto-Enteric fistula. Common presentation?

Answer 19

Massive bleeding in pt with prior aortic graft that erodes into duodenum; herald bleed (massive bleed that then stops)

Question 20

Cameron lesion. Type of bleeding?

Answer 20

Erosions or ulcerations that occur within a hiatal hernia; typically occult

Question 21

Endoscopic therapy techniques

Answer 21

Injection (epi, ST but helps you visualize area), hemostatic therapy (cauterizing), band ligation (common for esophageal varices), clips

Question 22

Lower GI bleeding presents with what? Common course?

Answer 22

Hematochezia, frequently stops spontaneously (intermittent)

Question 23

T/F: Lower GI bleeding is typically chronic

Answer 23

True

Question 24

Common causes of lower GI bleeding (4)

Answer 24

Hemorrhoid (painless, blood on tissue), anal fissure (pain during stool passage), colitis (urgency, tenesmus, pain, diarrhea), polyp/cancer (blood mixed with stool)

Question 25

Two causes of acute hemodynamically significant lower GI bleeds

Answer 25

1. Diverticulosis and 2. Arteriovenous malformations (AVMs)

Question 26

Most common causes of hemorrhoids (2)

Answer 26

Pregnancy and constipation

Question 27

Anal fissure presentaton, tx

Answer 27

Red blood with BM, tearing/burning pain, blood in toilet bowel, tx = topical medications

Question 28

T/F: It's always easy to find bleeding diverticulum

Answer 28

False: pts often have more than one diverticulum and the bleeding can be sporadic

Question 29

Colitis: presentation

Answer 29

Blood/cramping either acute (ischemia, infectious) or chronic (IBD, Crohn's)

Question 30

Can colon polyp's bleed? What percent of polyps and cancer bleeds are associated with acute lower GI bleeds?

Answer 30

Yes (also after polyp removal); 5%

Question 31

How to evaluate lower GI bleeding?

Answer 31

Endoscopy (colonoscopy) or nuclear scan

Question 32

Describe nuclear scan

Answer 32

Labeled RBC scan, and can be repeated within 24 hours if bleeding begins again

Question 33

Describe angiogram

Answer 33

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)

Question 34

What % of bleeding is not identified by upper or lower endoscopy? What is it called?

Answer 34

5%, "obscure" GI bleeding

Question 35

Causes of obscure GI bleeding

Answer 35

Small intestinal: Vascular (AVM), neoplastic, inflammatory diseases, Meckel's diverticulum; biliary; pancreatic

Question 36

Why does Meckel's diverticulum produce bleeding? Painful?

Answer 36

Heterotopic gastric mucosa --> acid --> ulceration --> bleeding; non-painful bleeding

Question 37

How to dx Meckel's?

Answer 37

Meckel's scan (nuclear) that looks for parietal cells

Question 38

Patent profile for Meckel's

Answer 38

Young males, obscure bleeding

Question 39

What is a push entroscopy? What is a surgical option? What is a non-invasive option?

Answer 39

Endoscopy of the small intestine, can reach the mid jejunum (4 ft); intra-operative endoscopy (very invasive); capsule endoscopy (camera)

Question 40

If you find something with a capsule endoscopy, what do you do next?

Answer 40

Double-balloon enteroscopy