Medbear Stomach Flashcards
Define Upper GI tract bleeding (UBGIT)
It is defined as bleeding that occurs proximal to the ligament of Treitz
What is ligament of Treitz
It is the SUSPENSORY MUSCLE of the duodenum that connects the DJ flexure to the connective tissue surrounding the celiac axis and SMA
State the clinical presentation of UBGIT
- Hematemesis (red blood or coffee ground vomitus)
- Melena
- Hemorrhagic shock (So, always assess patient’s hemodynamic status)
State factors that are predictive for UBGIT
- Patient-reported history of melena
- Melenic stool on examination
- Blood or coffee ground detected during NG lavage
- Ratio of BUN to serum Cr>30
Presence of blood clots in stool made an UBGIT less likely
Differentiate hemoptysis and hematemesis
Melena:
1. Define
2. Types
3. Differential
- Passage of altered blood (BLACK TARRY STOOL) that originates proximal to ligament of Treitz (90%)
- Types of melena:
- Fresh melena - jet black with sheen, tarry (suggest fairly acute bleeding)
- Stale melena - black-grey, dull, mixed with normal stool (suggest bleed which stopped followed with melena) - Differential -> IRON STOOL (Greenish hue/sedimentation turning the water green if gloved finger is stirred in a cup of water)
To determine the etiology of variceal bleed
1. Variceal bleeding
2. Non-variceal bleeding
What question should be asked if variceal bleeding is suspected?
- Any history of variceal bleeding?
- Any regular banding or OGDS screening and banding?
- Any history of CLD? Ask for the risk factor (alcohol ingestion, hepatitis B/C, any regular follow up for liver disease)
State (6) differentials for non-variceal bleeding
- PUD (most common cause)
- Stress ulcers
- Mallory-Weiss tear
- Dieulafoy’s disease - AVM of gastric fundus
- Malignancy (gastric/esophageal CA)
- Gastric antral vascular ecstasia
Illustrate the diagnostic study of acute GI bleed
What is the fluid resuscitation protocol if patient is hemodynamically stable?
- Nasal prong
- IV cannula -> 2 large bore 18G catheter inserted at antecubital fossa
- Blood investigations: GXM, FBC, U/E/Cr, PT/PTT/INR, LFT, Trop I
- ECG -> TRO cardiac event
What is the fluid resuscitation protocol if patient is hemodynamically unstable?
- Fluid resuscitation with crystalloids
- Run in 1L N/S fast and assess clinical response
- Restrictive transfussion strategy to keep Hb>7g/dL
- May consider platelets if patients has quantitative (<50k) or qualitative (on antiplatelet) deficits
- FFP if patients is on anti-coagulants or PT/PTT prolonged
What are the adjuncts in the management of UBGIT?
- NG tube if patient is having hematemesis
- Arterial line/CVP -> For monitoring hemodynamic status
- IDC (Indwelling catheter) insertion
- Intubate if patient having massive uncontrolled active hematemesis
Targets:
1. Keep MAP >60mmHg
2. Urine output >0.5mL/kg/hr
3. Hb >7 or >9 (IHD)
State the early medications of UBGIT
- IV Omeprazole 80mg bolus followed by 8mg/hr for 3 days
- If suspecting varices -> IV Somatostatins 250mcg followed by 250mcg/hr and IV ceftriaxone 1gm once
- If planning urgent endoscopy, KIV for IV erythromycin (For gastric emptying)
What are the indications of urgent OGD?
- Hemodynamic instability despite fluid resuscitation
- Active BGIT, in patient presenting with hematemesis and/or fresh melena
- Suspected variceal bleed (bleeding can be brisk)
State the types of therapeutic options for OGDS (injectable, thermal, mechanical)
Therapeutic options based on the following condition:
1. Varices
2. Non-variceal
How do you manage a case of re-bleeding in UBGIT?
- Repeat OGD and re-attempt endoscopic hemostasis
- If failure of endoscopic hemostasis
1. Surgery (2 goals, curative and decrease acid components)
2. Radiological intervention - CT mesenteric angiogram or mesenteric angiogram KIV embolization
Why is Blatchford Scoring system more favourable than Rockall score?
It is because there is no endoscopic component involved for Blatchford scoring system
State the type of hypersensitivity reaction in acute hemolytic transfusion reaction
Antibody-mediated (Type 2) hypersensitivity reaction
What are the complications of massive blood transfusion?
- Hypothermia
- Coagulopathy and Thrombocytopenia
- Electrolytes
- Acid-base disorders
- Transfusion-related acute lung injury
What are the dilated submucosal veins in gastroesophageal varices formed from?
Formed by the portocaval anastomosis between the left gastric veins and esophageal branches of azygous veins
When to suspect variceal source in UBGIT?
- Any previous variceal bleed
- Any history of chronic liver disease
- Any stigmata of chronic liver disease
State the pharmacological management of active variceal bleed
- IV broad spectrum antibiotic for 7 days
- IV somatostatin or IV octreotide for 3-5 days
- IV Omeprazole 80mg bolus + 8mg/hr for 3 days
- IV vitamin K (10mg) - routinely given to cirrhotic with coagulopathy
+/-
1. IV Terlipressin (vasoactive drug of choice)
2. Recombinant activated factor 7 -> To correct PT in cirrhotic
How would you manage a case of severe variceal bleeding?
Insertion of SB tube
Remember to protect the airway before inserting the SB tube
What is the definitive management of esophageal varices?
- Endoscopy
- To confirm diagnosis
- Therapeutic:
Sclerotherapy = induce inflammation and fibrosis -> Controls bleeding in 70%
Variceal band ligation = ligation is superior to sclerotherapy in initial control of bleeding
- Bleeding Gastric Varices ??
- TIPSS (Transjugular Intrahepatic Porto-Systemic Shunt)
Indications:
- Protracted bleeding
- Progression of coagulopathy
- Visceral hypo-perfusion
- Refractory ascites
Needle track is dilated until a portal pressure gradient of <12mmHg is achieved
(TIPSS is not a good long-term preventive strategy)
