Pathology -- Gastrointestinal Bleeding Flashcards
Give 4 types of GI bleeding in decreasing order of incidence
- UGI bleeding (60.6/100,000)
- LGI bleeding (35.7/100,000)
- Peptic ulcer bleeding (32.1/100,000)
- Colonic diverticular bleeding (23.9/100,000)
Case fatality for UGI and LGI bleeding
- UGI = 2.45%
- LGI = 1.47%
Case fatality of patients > 75 years with bleeding
3.54%
Flowchart to categorize GI bleeding
4 upper GI presenting symptoms
- 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
3 of the most common causes of severe UGI bleeding
- Gastric or duodenal ulcer (38%)
- Gastric or esophageal varices (16%)
- Erosive esophagitis (13%)
4 ways to diagnose UGI bleeding
- Medical history
- Vital signs and physical exam
- Lab testing
- Blood urea nitrogen level increases to a greater extent than creatinine level
6 findings in medical history that may point to UGI
- ASA
- NSAIDs
- Liver disease
- Vomiting
- NG tube
- GERD
4 lab tests for UGI bleeding
- CBC (hemoglobin, platelets)
- Chemistry study
- Liver study
- Coagulation study
4 parts of the initial management of UGI bleeding
- ABCs (IV, intubation, INR correction)
- Type and Cross-Match
- Fluid resuscitation
- Crystalloid
- Blood
- Risk stratification
- Clinical (Blatchfod, Rockall, AIMS65 scores)
- Endoscopic
When should patients undergo endoscopic evaluation in the event of UGI bleeding
Within 12 - 24 hours
Describe the usefulness of endoscopy with UGI bleeding
Identification of the site of bleeding with:
- 92% sensitivity
- ~100% specificity
Provides hemostasis if needed
2 drugs to administer just prior to endoscopy of UGIB
- IV prokinetic agent in some (Erythromycin, 250 mg 30 - 60 min prior)
- Proton pump inhibitor therapy
What is the benefit of administering an IV prokinetic agent pre-endoscopy for UGIB patients?
Improve visualization
Benefit of administering pre-endoscopic proton pump inhibitor therapy for UGIB
Has not shown to alter clinical outcomes, but may downstage the severity of the lesion and decrease the need for endoscopic intervention
Goal of endoscopic therapy for UGIB
Stop acute bleeding and reduce the risk of recurrent bleeding
4 available treatments in endoscopic therapy
- Injection
- Thermal coagulation
- Mechanical compression (clips)
- Hemostatic powders
For which kind of lesions is endoscopic therapy reserved?
Lesions that have high-risk stigmata
3 alternative management strategies for refractory UGIB
- Radiological percutaneous procedures (embolization, shunts)
- Surgery
- In rare cases, if malignancy, radiation therapy
Medical therpay for non variceal UGIB: why do it?
Adjunct to endoscopic hemostasis in patients with high risk endoscopic stigmata
Effect of proton pump inhibitors for non variceal UGIB
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
How is variceal UGIB treated?
Combination of pharmacotherapy, endoscopy, radialogical therapy and (temporarily) balloon tamponade or esophageal stenting
2 pharmacotherapy drugs for variceal UGIB
- Octreotide
- Somatostatin
2 endoscopy treatments for variceal UGIB
- Band ligation
- Sclerotherapy
Radiological therapy for variceal UGIB
Prosthetic shunting
What does UGIB prognosis depend on?
The cause of bleeding
Give the prognosis of UGIB based on non-variceal vs. variceal and their rates of rebleeding, surgery and mortality
Flowchart for overall management of NVUGIB
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
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
What is the advantage of colonoscopy for LGIB
Allows for diagnosis and possible hemostasis of amenable lesions
3 most common colonic sources of severe hematochezia
- Diverticulosis
- Internal hemerrhoids
- Ischemic colitis
2 therapies for LGIB
Urgent colonscopy vs. elective colonoscopy
Endoscopic therapy similar to UGIB
If colonoscopy does not reveal the source of bleeding, what should be done?
Upper GI endoscopic evaluation
If both colonscopy and endoscopic evaluation are negative, what should be done?
Capsule endoscopy
Alternative therapies if LGI bleeding persists or is too rapid to perform a colonscopy
- Tagged red blood cell nuclear scan
- Angiography
When is a red blood cell scan useful?
Only if LGIB is at a rate of at least 0.1 mL/minute
When is angiography useful for localization of bleeding?
Only when the bleeding rate is of at least 0.5 mL/min
3 alternative therapies for LGIB
- Angiographic embolization
- Infusion of vasoconstrictors
- Surgery
What is the rate of success and risk for angiographic embolization/infusion of vasoconstrictors
Success = 80%
Risk of causing local ischemia = 10%
Why is surgical management rarely required for hemostasis of LGIB?
Most bleeding is either self-limited or easily managed with medical or endoscopic therapy
For which patients with LGIB is surgery reserved?
Patients with malignant lesions and recurrent or persistent ischemic colitis or diverticular hemorrhage
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%
Flowchart to determine therapy for LGIB
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
What method will yield a diagnosis in about half of obscure GIB patients?
Repeated gastroscopy / colonoscopy
Percentage of GIB cases that are considered to be obscure
5%
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
Most common sources of small intestinal bleeding
- Vascular lesions (angiectasis)
- Ulcers
- Tumors
Other causes of oscure GIB (not necessarily small intestine)
- Lesions within reach of standard endoscopes not recognized as the bleeding site
- Intermittently bleeding lesions
2 lesions within reach of standard endoscopes which are not recognized as the bleeding site in obscure GIB
- Cameron’s ulcers
- Internal hemerrhoids
Example of an intermitently bleeding lesion which could be defined as obscure GIB
Dieulafoy’s lesion
What can result in iron deficiency?
- Overt or occult blood loss
- Iron malabsorption
- Chronic red blood cell destruction
Examples of conditions that cause overt or occult blood loss
GI tract lesions
Menorrhagia
2 conditions that cause iron malabsorption
Celiac disease
Atrophic gastritis
Condition that causes chronic red blood cell destruction
Hemolysis
Flow chart for approach to overt obscure GIB that involves active bleeding
NOTE: Go to flow chart for inactive bleeding if all tests negative
Flow chart for approach to overt obscure GIB that involves inactive bleeding
Frequency of lesion types found during double-balloon enteroscopy for obscure GIB
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
How to investigate GI if IDA tests are negative
Colonoscopy followed by upper endoscopy
What method should be performed to look for evidence of celiac disease?
Duodenal biopsies
If all tests for IDA are negative, what should be performed?
Capsule endoscopy with a work up for non-GI causes if negative
