Module 2: GI bleeding

Question 1

Which structure in the stomach is used to differentiate between upper and lower GI bleeding

Answer 1

-Ligament of Treitz
if abover the ligament of Treitz -> upper (stomach, duodenum)

if below -> lower (jejunum, ileum, large intestine, rectum, anus)

Question 2

What are the possible causes of upper GI bleeding?

Answer 2

-Peptic ulcer disease (PUD)

-Liver cirrhosis -> Variceal Bleed (covered later)

Question 3

What are the causes of lower GI bleeding?

Answer 3

-Ischemic bowel disease: one portion of the bowel has died and is bleeding (EMERGENCY, surgical resection + antibiotics)

-Intussusception (often in peds, surgical repair)

-Meckel diverticulum: a pouch that can burst and bleed, surgical repair

-Diverticulosis: pouches are inflamed
-Diverticulitis: infected pouches, need antibiotics

-Inflammatory bowel disease

-anal fissures: tear in the lining of the rectum (often due to severe constipation -> treat constipation)

-hemorrhoids: enlarged blood vessels in the rectum: sitz bath, topical steroids
-cancer

Question 4

How to treat an Ischemic bowel disease?

Answer 4

-Lower GI bleed
-EMERGENCY -> surgical resection
-antibiotics: gram negatives and anaerobes

Question 5

Signs of upper GI bleed

Answer 5

Upper GI bleed: Melena (dark, tarry, sticky blood)&raquo_space; Hematochezia (bright red blood)

Lower GI bleed: Hematochezia&raquo_space; Melena

with:
+/- pain
+/- hemodynamic stability (hypotension, tachycardia depending on the severity of the bleed)
Anemia

Question 6

Why is Melena often seen in Upper GI bleeding?

Answer 6

The blood has time to clot when passing through the stomach, intestine, and rectum

Question 7

Treatment of upper GI bleed

Answer 7

-Assess hemodynamics (hypotensive, tachycardia)
-Assess anemia: transfuse if Hbg > 7g/dl
-Endoscopic therapy to stop the bleeding

-Meds:
IV PPI for 72h then PO BID PPI for 2 weeks

Question 8

IV regimen for upper GI bleeding

Answer 8

IV PPI continuous infusion: Esomeprazole 80 mg bolus, then 8mg/h X 72h

IV PPI intermittent infusion: Pantoprazole or Esomeprazole 40 mg BID X 72h

(then PO BID PPI for 2 weeks)

Question 9

Treatment Upper GI bleed due to H. pylori

Answer 9

H. pylori treatment: TRIPLE or Quadruple therapy
document cure and DC PPI (taper down)

Question 10

Treatment Upper GI bleed due to NSAID

Answer 10

DC NSAID or change to partially selective
-4-8 weeks of daily PPI

Question 11

Treatment Upper GI bleed due to ASA

Answer 11

DC ASA if possible
-4-8 weeks of daily PPI

Question 12

Treatment of lower GI bleeding

Answer 12

-Assess hemodynamics (hypotensive, tachycardia)
-Assess anemia: transfuse if Hbg > 7g/dl
-based on the cause -> diagnostic colonoscopy

Question 13

Pharmacotherapy of lower GI bleeding

Answer 13

-Hemorrhoids: topical steroids
-Diverticulosis: symptomatic control (nausea, pain)
-Diverticulitis: 4-7d antibiotics covering gram-negative enterics and anaerobes
-Inflammatory bowel disease: IBD lecture

Question 14

What are the antibiotics to use for Diverticulitis

Answer 14

for gram-negative enterics and anaerobes

4-7 days
option 1: Augmentin
option 2 (PO or IV): Cipro (for gram-negatives) and Metronidazole (Flagyl, for anaerobes)
option 3 (IV): Pip/Tazo (Zosyn)
option 4 (IV): Cipro/Levo + Flagyl