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Block D - Digestion and Metabolism > Pathology -- Gastrointestinal Bleeding > Flashcards

Pathology -- Gastrointestinal Bleeding Flashcards

1
Q

Give 4 types of GI bleeding in decreasing order of incidence

A
  1. UGI bleeding (60.6/100,000)
  2. LGI bleeding (35.7/100,000)
  3. Peptic ulcer bleeding (32.1/100,000)
  4. Colonic diverticular bleeding (23.9/100,000)
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2
Q

Case fatality for UGI and LGI bleeding

A
  • UGI = 2.45%
  • LGI = 1.47%
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3
Q

Case fatality of patients > 75 years with bleeding

A

3.54%

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4
Q

Flowchart to categorize GI bleeding

A
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5
Q

4 upper GI presenting symptoms

A
  • Hematemesis (vomiting of blood or coffe-ground material)
  • Melena (black, tarry stool)
  • +/- hypovolemic shock
  • Hematochezia (passage of red blood or clots per rectum) – 15 - 20% of patients
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6
Q

3 of the most common causes of severe UGI bleeding

A
  1. Gastric or duodenal ulcer (38%)
  2. Gastric or esophageal varices (16%)
  3. Erosive esophagitis (13%)
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7
Q

4 ways to diagnose UGI bleeding

A
  • Medical history
  • Vital signs and physical exam
  • Lab testing
  • Blood urea nitrogen level increases to a greater extent than creatinine level
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8
Q

6 findings in medical history that may point to UGI

A
  • ASA
  • NSAIDs
  • Liver disease
  • Vomiting
  • NG tube
  • GERD
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9
Q

4 lab tests for UGI bleeding

A
  • CBC (hemoglobin, platelets)
  • Chemistry study
  • Liver study
  • Coagulation study
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10
Q

4 parts of the initial management of UGI bleeding

A
  • ABCs (IV, intubation, INR correction)
  • Type and Cross-Match
  • Fluid resuscitation
    • Crystalloid
    • Blood
  • Risk stratification
    • Clinical (Blatchfod, Rockall, AIMS65 scores)
    • Endoscopic
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11
Q

When should patients undergo endoscopic evaluation in the event of UGI bleeding

A

Within 12 - 24 hours

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12
Q

Describe the usefulness of endoscopy with UGI bleeding

A

Identification of the site of bleeding with:

  • 92% sensitivity
  • ~100% specificity

Provides hemostasis if needed

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13
Q

2 drugs to administer just prior to endoscopy of UGIB

A
  • IV prokinetic agent in some (Erythromycin, 250 mg 30 - 60 min prior)
  • Proton pump inhibitor therapy
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14
Q

What is the benefit of administering an IV prokinetic agent pre-endoscopy for UGIB patients?

A

Improve visualization

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15
Q

Benefit of administering pre-endoscopic proton pump inhibitor therapy for UGIB

A

Has not shown to alter clinical outcomes, but may downstage the severity of the lesion and decrease the need for endoscopic intervention

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16
Q

Goal of endoscopic therapy for UGIB

A

Stop acute bleeding and reduce the risk of recurrent bleeding

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17
Q

4 available treatments in endoscopic therapy

A
  • Injection
  • Thermal coagulation
  • Mechanical compression (clips)
  • Hemostatic powders
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18
Q

For which kind of lesions is endoscopic therapy reserved?

A

Lesions that have high-risk stigmata

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19
Q

3 alternative management strategies for refractory UGIB

A
  • Radiological percutaneous procedures (embolization, shunts)
  • Surgery
  • In rare cases, if malignancy, radiation therapy
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20
Q

Medical therpay for non variceal UGIB: why do it?

A

Adjunct to endoscopic hemostasis in patients with high risk endoscopic stigmata

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21
Q

Effect of proton pump inhibitors for non variceal UGIB

A

Profound acid suppression that may promote platelet aggregation and clot formation –> reduce re-bleeding and surgery rates

In patients with high-risk stigmata post endoscopic therapy, high-dose IV PPI x72 hours reduces mortality

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22
Q

How is variceal UGIB treated?

A

Combination of pharmacotherapy, endoscopy, radialogical therapy and (temporarily) balloon tamponade or esophageal stenting

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23
Q

2 pharmacotherapy drugs for variceal UGIB

A
  • Octreotide
  • Somatostatin
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24
Q

2 endoscopy treatments for variceal UGIB

A
  • Band ligation
  • Sclerotherapy
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25
Radiological therapy for variceal UGIB
Prosthetic shunting
26
What does UGIB prognosis depend on?
The cause of bleeding
27
Give the prognosis of UGIB based on non-variceal vs. variceal and their rates of rebleeding, surgery and mortality
28
Flowchart for overall management of NVUGIB
29
How to diagnose lower GI bleeding
* History, physical exam, lab evaluation * History of diverticulosis, abdominal cramping followed by bloody diarrhea, reent polypectomy * NOTE: Physical exam and lab findings as per UGIB
30
4 key points for LGIB management
* Resuscitation as per UGIB * Most patients then need andoscopic evaluation * Flexible sigmoidoscopy/anoscopy, especially if anorectal/distal colon bleeding * Colonoscopy
31
What is the advantage of colonoscopy for LGIB
Allows for diagnosis and possible hemostasis of amenable lesions
32
3 most common colonic sources of severe hematochezia
* Diverticulosis * Internal hemerrhoids * Ischemic colitis
33
2 therapies for LGIB
Urgent colonscopy vs. elective colonoscopy Endoscopic therapy similar to UGIB
34
If colonoscopy does not reveal the source of bleeding, what should be done?
Upper GI endoscopic evaluation
35
If both colonscopy and endoscopic evaluation are negative, what should be done?
Capsule endoscopy
36
Alternative therapies if LGI bleeding persists or is too rapid to perform a colonscopy
* Tagged red blood cell nuclear scan * Angiography
37
When is a red blood cell scan useful?
Only if LGIB is at a rate of at least 0.1 mL/minute
38
When is angiography useful for localization of bleeding?
Only when the bleeding rate is of at least 0.5 mL/min
39
3 alternative therapies for LGIB
* Angiographic embolization * Infusion of vasoconstrictors * Surgery
40
What is the rate of success and risk for angiographic embolization/infusion of vasoconstrictors
Success = 80% Risk of causing local ischemia = 10%
41
Why is surgical management rarely required for hemostasis of LGIB?
Most bleeding is either self-limited or easily managed with medical or endoscopic therapy
42
For which patients with LGIB is surgery reserved?
Patients with malignant lesions and recurrent or persistent ischemic colitis or diverticular hemorrhage
43
How is the prognosis for LGIB and what does it depend on?
* Depends on cause of bleeding * Favorable in most cases * Overall mortality rate from LGIB is 2 - 4%
44
Flowchart to determine therapy for LGIB
45
Define obscure GIB
Bleeding that is persistent or recurrent, despite a negative initial GI evaluation, including: * Upper endoscopy * Colonoscopy * Radiologic evaluation of the small intestine
46
What method will yield a diagnosis in about half of obscure GIB patients?
Repeated gastroscopy / colonoscopy
47
Percentage of GIB cases that are considered to be obscure
5%
48
Where is the source of bleeding in the majority of patients with obscure GIB?
Parts of the small intestine that are beyond the reach of an upper endoscope or colonoscope
49
Most common sources of small intestinal bleeding
1. Vascular lesions (angiectasis) 2. Ulcers 3. Tumors
50
Other causes of oscure GIB (not necessarily small intestine)
* Lesions within reach of standard endoscopes not recognized as the bleeding site * Intermittently bleeding lesions
51
2 lesions within reach of standard endoscopes which are not recognized as the bleeding site in obscure GIB
* Cameron's ulcers * Internal hemerrhoids
52
Example of an intermitently bleeding lesion which could be defined as obscure GIB
Dieulafoy's lesion
53
What can result in iron deficiency?
* Overt or occult blood loss * Iron malabsorption * Chronic red blood cell destruction
54
Examples of conditions that cause overt or occult blood loss
GI tract lesions Menorrhagia
55
2 conditions that cause iron malabsorption
Celiac disease Atrophic gastritis
56
Condition that causes chronic red blood cell destruction
Hemolysis
57
Flow chart for approach to overt obscure GIB that involves active bleeding
NOTE: Go to flow chart for inactive bleeding if all tests negative
58
Flow chart for approach to overt obscure GIB that involves inactive bleeding
59
Frequency of lesion types found during double-balloon enteroscopy for obscure GIB
60
GI evaluation for iron deficiency anemia is indicated in what 3 groups of people?
* Adult men * Pre-menopausal women with a -ve GU w/u * All post-menopausal women
61
How to investigate GI if IDA tests are negative
Colonoscopy followed by upper endoscopy
62
What method should be performed to look for evidence of celiac disease?
Duodenal biopsies
63
If all tests for IDA are negative, what should be performed?
Capsule endoscopy with a work up for non-GI causes if negative

Block D - Digestion and Metabolism (29 decks)

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