Medbear Stomach Flashcards

1
Q

Define Upper GI tract bleeding (UBGIT)

A

It is defined as bleeding that occurs proximal to the ligament of Treitz

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2
Q

What is ligament of Treitz

A

It is the SUSPENSORY MUSCLE of the duodenum that connects the DJ flexure to the connective tissue surrounding the celiac axis and SMA

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3
Q

State the clinical presentation of UBGIT

A
  • Hematemesis (red blood or coffee ground vomitus)
  • Melena
  • Hemorrhagic shock (So, always assess patient’s hemodynamic status)
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4
Q

State factors that are predictive for UBGIT

A
  • 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

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5
Q

Differentiate hemoptysis and hematemesis

A
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6
Q

Melena:
1. Define
2. Types
3. Differential

A
  1. Passage of altered blood (BLACK TARRY STOOL) that originates proximal to ligament of Treitz (90%)
  2. 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)
  3. Differential -> IRON STOOL (Greenish hue/sedimentation turning the water green if gloved finger is stirred in a cup of water)
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7
Q

To determine the etiology of variceal bleed
1. Variceal bleeding
2. Non-variceal bleeding

What question should be asked if variceal bleeding is suspected?

A
  • 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)
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8
Q

State (6) differentials for non-variceal bleeding

A
  • PUD (most common cause)
  • Stress ulcers
  • Mallory-Weiss tear
  • Dieulafoy’s disease - AVM of gastric fundus
  • Malignancy (gastric/esophageal CA)
  • Gastric antral vascular ecstasia
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9
Q

Illustrate the diagnostic study of acute GI bleed

A
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10
Q

What is the fluid resuscitation protocol if patient is hemodynamically stable?

A
  • 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
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11
Q

What is the fluid resuscitation protocol if patient is hemodynamically unstable?

A
  • 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
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12
Q

What are the adjuncts in the management of UBGIT?

A
  • 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)

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13
Q

State the early medications of UBGIT

A
  • 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)
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14
Q

What are the indications of urgent OGD?

A
  • Hemodynamic instability despite fluid resuscitation
  • Active BGIT, in patient presenting with hematemesis and/or fresh melena
  • Suspected variceal bleed (bleeding can be brisk)
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15
Q

State the types of therapeutic options for OGDS (injectable, thermal, mechanical)

Therapeutic options based on the following condition:
1. Varices
2. Non-variceal

A
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16
Q

How do you manage a case of re-bleeding in UBGIT?

A
  • 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
17
Q

Why is Blatchford Scoring system more favourable than Rockall score?

A

It is because there is no endoscopic component involved for Blatchford scoring system

18
Q

State the type of hypersensitivity reaction in acute hemolytic transfusion reaction

A

Antibody-mediated (Type 2) hypersensitivity reaction

19
Q

What are the complications of massive blood transfusion?

A
  • Hypothermia
  • Coagulopathy and Thrombocytopenia
  • Electrolytes
  • Acid-base disorders
  • Transfusion-related acute lung injury
20
Q

What are the dilated submucosal veins in gastroesophageal varices formed from?

A

Formed by the portocaval anastomosis between the left gastric veins and esophageal branches of azygous veins

21
Q

When to suspect variceal source in UBGIT?

A
  • Any previous variceal bleed
  • Any history of chronic liver disease
  • Any stigmata of chronic liver disease
22
Q

State the pharmacological management of active variceal bleed

A
  • 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

23
Q

How would you manage a case of severe variceal bleeding?

A

Insertion of SB tube
Remember to protect the airway before inserting the SB tube

24
Q

What is the definitive management of esophageal varices?

A
  1. 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

  1. Bleeding Gastric Varices ??
  2. 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)
25
Q

What is the best option to offer to a patient for secondary prophylaxis of variceal bleeding?

A

Combination of
- Band ligation (3 weekly ligation until completely obliterated)
- Non-selective Beta-blockers (Propranolol unless CI)

26
Q

What are the best options to offer a patient for primary prophylaxis of variceal bleeding?

A
  • Non-selective Beta-blocker (Propranolol and Nadolol)
  • If contraindicated to BB -> Long-acting nitrates (ISOSORBIDE MONONITRATE)

Indication for primary prophylaxis:
- Large varices (grade 3) or Medium varices (grade 2)
with endoscopic red signs
- Child’s C cirrhosis

27
Q

State the red signs of endoscopic stigmata of recent hemorrhage (ESRH)

A
  • Red wale marks (longitudinal red streaks)
  • Cherry red spots (Flat discrete spots)
  • Hematocystic spots (raised discrete spots - resemble “blood blisters”)
  • Diffuse erythema
28
Q

State the common risk factors of PUD

A
  • H.pylori infection
    H.pylori inhibits D cells (Decreased somatostatin levels) -> hypergastrinemia and acid hypersecretion
  • NSAID
    1. 8X increased risk in duodenal ulcers
    2. 40X increased risk in stomach ulcers
  • Smoking (2X increased risk compared to non-smokers)

Other causes:
- Zollinger Ellison Syndrome
- Previous peptic ulcer
- Psychological stress
- Alcohol
- Other drugs = corticosteroids, anticoagulants

28
Q

State (2) common site of PUD

A
  • Duodenum - proximal (75%)
  • Stomach - lesser curvature, antrum (20%), greater curve