Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

ACG Guidelines > Mgmt of Pts w/ Acute LGIB (2016) > Flashcards

Mgmt of Pts w/ Acute LGIB (2016) Flashcards

1
Q

Acute over lower GI bleeds account for what percentage of all GI bleed cases?

A

20%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What percentage of pts w/ presumed LGIB are ultimately found to have an upper GI source?

A

15%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

define lower GI bleed

A

hematochezia originating from either the colon or rectum. rarely, bleeds from cecum/R colon can present w/ melena.

We no longer define LGIB as everything distal to ligament of Treitz (small intestine bleeding = middle GI bleeding)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

4 goals of initial assessment

A

severity, location of bleed, etiology, resuscitation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

useful hints in the history that would suggest:

  • colitis
  • malignancy
A

colitis - abdominal pain, diarrhea

malignancy - weight loss, altered bowel habits

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

risk factors for poor outcomes in LGIB?

A

hemodynamic instability, ongoing bleeding (gross blood on initial DRE, recurrent hematochezia), comorbidities, age >60 y/o, h/o diverticulosis or angioectasia, elevated Cr, hct <35%.

consider dispo to ICU

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

goals and method of initial hemodynamic resuscitation

A

IVF (crystalloid) to normalize BP and HR before endoscopy (strong rec; very low qual ev). Improvement in mortality, MI, and time in ICU was not statistically significant in this one study.

RBC to maintain Hgb >7 (consider goal >9 in pts w/ massive bleeding, significant comorbidities esp ACS, symptomatic peripheral vascular disease, or a possible delay in receiving therapeutic interventions (conditional rec; low-qual ev)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What specific comorbidities should you ask about?

A

prior GI bleeds, abdominal and/or vascular surgeries, PUD, IBD, abdominopelvic radiation.

Also in general ask about cardio, pulm, renal, adn hepatic diseases that may put pt at high risk of poor outcome and change management.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What meds (current, recent) should you ask about?

A

Meds that can affect bleeding risk - NSAIDs, antiplatelets, anticoagulants (even SSRIs’ effects w/ antiplatelets)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what BUN/Cr ratio suggests UGI source of bleed? What’s the positive LR?

A

> 30:1

LR 7.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What’s the likelihood of UGI bleed if you find red blood and clots on DRE?

A

unlikely to be UGI source

LR 0.05

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

If UGI source is suspected, what’s the utility of a negative nasogastric aspirate?

A

not useful, since NPV is 64%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What INR window is safe for endoscopic hemostasis?

A

INR 1.5 - 2.5 before or concomitant w/ administration of reversal agents

Use reversal agents BEFORE endoscopy in pts w/ INR > 2.5 (conditional rec, very low qual ev)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

When do you trigger platelet transfusions?

A

to maintain plt >50k in pts w/ severe bleeding and thos requiring endoscopic hemostasis (condition rec, very low qual ev)

Also give plt and plasma if pt receiving massive RBC transfusions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Define massive RBC transfusion

A

traditionally, >10 pRBC units in 24hr.

more recently, 3+ units w/n 1hr

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what are the reversal agents for DOACs?

A

For dabigatran (Pradaxa; reversible thrombin inhibitor; watch out for concomitant use w/ dronederone and ketoconazole; half life 12-14hr), it’s idarucizumab (Praxbind; monoclonal Ab against dabigatran; neutralizes dabigatran w/n minutes, full hemostasis at 11hr). Uptodate also suggests oral activated charcoal if ingestion w/n 2hrs to remove pro-drug of dabigatran. may also remove w/ dialysis.

For direct factor Xa inhibitors (apixaban/eliquis, rivaroxaban/xarelto, edoxaban/savaysa, consider andexanet alfa, tranexamic acid, unactivated 4-factor PCC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what is the diagnostic yield of colonoscopy for lower GIB?

A

48-90%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what are the most common causes of acute severe LGIB?

A

diverticulosis, angioectasia, post-polypectomy bleeding, ischemic colitis

19
Q

What are less common causes of LGIB?

A

colorectal polyps/neoplasms, Dieulafoy’s lesions, IBD, anorectal conditions (rectal ulcer, radiation proctitis, rectal varices)

20
Q

Why is it important to intubate the TI?

A

to rule out proximal blood suggestive of small bowel lesion

21
Q

What is the recommended prep volume and timing of diagnostic colo for LGIB?

A

4-6L of PEG over 3-4hrs until rectal effluent is clear of blood and stool. Can do colo w/n 1-2hr of bowel prep completion

22
Q

what are possible complications of PEG prep?

A

rare, but aspiration pneumonia, fluid and electrolyte imbalances.

23
Q

What are the advantages of urgent colonoscopy for LGIB?

A

Urgent colo (w/n 12-24hrs) improves diagnostic and therapeutic yield, a/w shorter hospitalization.

Unclear if urgent colo improves rates of rebleeding or need for surgery

Takeaway:
perform colo w/n 24hr to improve diagnostic and therapeutic yield (conditional rec; low qual ev)

24
Q

what is the rate of adverse events w/ colonoscopic hemostasis for acute LGIB?

A

0.3-1.3%

25
Q

What are the endoscopic hemostasis options?

Which is better for LGIB?

A
  • clips
  • bands
  • epi
  • contact (heat, bipolar/multipolar electrocoag)
  • noncontact (argon plasma coag)

lack of studies on comparing hemostasis options in LGIB

26
Q

which LGIB etiologies are most amenable to endoscopic hemostasis?

A

diverticuli, angioectasia, and poly-polypectomy bleeding

27
Q

indications for endoscopic hemostasis for diverticulosis?

Theoretical best method and why.

A

Indications for hemostasis of diverticuli:

  • active bleeding
  • nonbleeding visible vessel
  • adherent clot that can’t be removed w/ vigorous washing and suctioning
Best method (theoretically):
clips. avoids the risk of transmural injury and perf that thermal therapies carry.

can place clips directly over bleeding site or over entire diverticulum orifice (‘zipper’)

Caution:
if choosing to band, be careful for R-sided diverticulum since you can get serosal entrapment and inclusion of muscularis propia (L colon has thicker mucosal wall).

28
Q

what is endoscopic hemostasis indicated for angioectasias?

A

when there’s e/o acute or chronic blood loss

29
Q

best mode of hemostasis for angioectasias? why?

A

contact and noncontact thermal tx

noncontact (APC) is more common - easy to use, safe, efficiencient, improves Hgb levels and reduces blood transfusions

30
Q

APC settings for angioectasias?

A

20-60 W (lower power in R colon)

gas flow rate 1-2.5l/min

pulses of 0.5 - 2 sec

may lift larger (>10mm) angioectasias in R colon w/ submucosal saline injection before coagulation

31
Q

what are risk factors for post-polypectomy bleeding?

A

large poly (>2cm)
thick stalk
R colon location
resumption of antithrombotic tx

32
Q

preferred hemostasis method for post-polypectomy bleeds?

A

clips - limits additional tissue injury that happens w/ contact thermal coagulation tx

33
Q

which LGIB etiologies are generally not amenable to durable endoscopic hemostasis?

A

ischemic colitis
colitis from IBD
colorectal neoplasms

treat medically and/or surgically the underlying etiology

34
Q

Pros and cons of angiography

A

PROS:
- allows localization and tx (angiography) if brisk ongoing bleeding precludes hemodynamic stabilization and bowel prep

CONS:
- requires active bleeding to identify lesion- risk of bowel ischemia (1-4% in more recent series) after selective embolization

reserved for pts w/ very brisk ongoing bleeds

35
Q

best use of tagged RBC

A

since you can do repeated scans after the initial injection of tagged RBCs, you can evaluate intermittent, obscure-overt GI bleeding more effectively

unclear if it’s helpful in localizing a lesion before angiography

36
Q

Pros and cons of CT angiography

A

PROS:
almost 100% accurate at localizing bleed site

CONS:
less sensitive in identifying lesions compared to scintigraphy

CONCLUSION:
CT angiography still a reasonable first-line screen if needed before angiography or emergent surgery b/c it’s faster and more accurate than tagged RBC’s.

37
Q

what is the rate of rebleeding for LGIB?

which etiologies are most well known to cause rebleeding?

A

poorly characterized

for early rebleeding (bleed befiore hospital d/c): 22%

for late rebleeding: 16%

diverticular and angioectasia bleeds

38
Q

in which etiologies of LGIB especially should non-aspirin NSAID use be avoided?

A

LGIB’s from angioectasias and diverticuli (strong rec; low qual ev)

39
Q

What should you do about aspirin secondary ppx for pt w/ high-risk CV disease and presentation of LGIB?

A

continue use for secondary ppx. avoid for primary ppx if pt is not high risk for cardiovascular events since there’s only 0.07% absolute risk reduction per year (strong rec; low qual ev)

40
Q

For pts w/ dual antiplatelet therapy or monotherapy w/ a non-aspirin antiplatelet agent:

1 - when to resume antiplatelet therapy?

2 - any situation where you shouldn’t hold DAPT?

A

1 - asap and at least w/n 7 days based on multi-D assessment of CV and GI risk and adequacy of endoscopic therapy. ASA use shouldn’t be stopped.

2 - don’t stop DAPT if pt had ACS w/n the past 90 days or PCI w/n the past 30 days (strong rec; low qual ev)

41
Q

What is the difference in rate of rebleeding for endoscopic modalities vs conservative care for angioectasias?

A

no difference in rate of rebleeding for angioectasias (endoscopic modalities vs conservative care)

42
Q

what is the rate of rebleeding for angioectasias?

A

w/ conservative/placebo therapy, 37-45% at 1yr; 58-64% at 2yrs.

43
Q

in a study of aspirin, plavix, and PPI therapy following PCI, LGIB was more common than UGIB (74% vs 26% of bleeds).

Why might that be?

A

antiplatelet-associated rebleeds may be higher in LGIB than UGIB given lack of prophylactic measures including PPI, H pylori tx.

ACG Guidelines (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions