Patient Presentation: GI Hemorrhage Flashcards
Identify the appropriate terms for the following definitions
- bright red blood in stool
- dark tarry stools
- bright red or coffee ground looking vomitus
- no obvious bleeding but positive fecal occult blood test or iron deficiency anemia
- Hematochezia
- (ask if red velvet cake– or anythign else)
- Melena
- (can also be caused by pepto-bismol or iron supplements)
- Hematemesis
- Occult bleeding
What is the boundary to determine an upper or lower GI bleed?
- Upper GI
- above ligament of Treitz (at duodenal jejunal flexure)
- hematemesis
- melena
- if brisk, can get hematochezia
- will have hyperactive bowel
- Lower GI
- below the ligament of Treitz (at duodenal jejunal flexure)
- often hematochezia
- most common cause = hemorrhoids
What are possible (12) main complaints for a patient with a GI bleed?
- abdominal pain
- diarrhea
- fatigue
- dyspnea
- dizziness
- rthostasis
- hypotension
- tachycardia
- red blood per rectum
- black tarry stools
- vomiting blood
- chest pain
What are the important factors in determing an acute vs. chronic problem?
- timing of onset
- stability of patient
- symptomatic presentation
- acute
- hematochezia
- melena
- hematemesis
- chronic
- may be occult
- acute
How will you stabilize a patient when they present with acute GI bleed?
-
Stabilize
- vitals
- plus orthostatics
- 10 point decrease systolic pressure or 10 beat increase in heart rate from lying to sitting or sitting to standing = positive = 15% blood loss
- tachycardia, hypotension, tachypnea, or metnal status change = 30% blood loss
- 2 large bore IV’s
- if shock, place central line
- resuscitate with IV fluids and/or blood
- 7g/dl or below = transfution
- Hemoglobin may take 48 hrs to drop
- lower mortality & decreased risk of transfusion complications
- complication from inadequate circulatory volume or red cells (kidney injury, MI, stroke, etc.)
- 7g/dl or below = transfution
- blood products: if coaguopathy
- fresh frozen plasma
- platelets
- vitals
Patient: 67 year old female presents c/o dizziness and SOB (short of breath) as well as frequent bright red bowel movements
Vitals:
- HR: 110
- BP: 100/67
- RR: 16
- Temp: 98.6
- Orthostatics
- BP drops minimally but HR goes up to 122
How do you stabilize?
- Positive orthostatice: lost 15%
- tachycardic– actually lost 30%
- Place 2 large bore IV’s and start running NS (normal saline)
The evaluation of a patient with a GI bleed consists of what components?
- History and Physical
- duration (acute/chronic)
- discomfort (location)
- associated symptoms (weight loss, fevers)
- meds (know if patient has coaguopathy, NSAIDs)
- past surgical history
- family history
- social history (alcohol?)
- medical history (GERD?)
- Endoscopy
- Lab
Patient: 67 year old female presents c/o dizziness and SOB (short of breath) as well as frequent bright red bowel movements
- History
- Has been bleeding for <24 hrs
- Hematochezia
- no pain
- has associated SOB (shortness of breath)
- on aspirin
- previous colonoscopy without polyps
- no significant family history
- previous smoker: quit 30 years ago
- has had mild systolic heart failure noted on previous ECHO
- Physical
- vitals
- digital rectal examination
- cardiovascular exam
- respiratory exam
- abdominal exam
- Exam shows patient to be in mild distress, with slight conversational dyspnea. Digital rectal exam palpation unremarkable but positive for gross blood. Auscultation of the heart reveals tachycardia, and lung sounds are clear. Abdomen has hyperactive bowel sounds but is nontender
What are you thinking and what labs would you order at this point?
- History
- hematochezia: quick upper GI or lower GI
- Physical
- vitals – not great
- digital rectal examination
- already know blood in stool
- cardiovascular exam
- tachycardic
- angina
- Hyperactive bowel indicated upper GI problem
- Labs
- CBC
- looking for anemia
- Type and Cross
- b/c concerned about needing transfusion
- CMP
- renal dysfunction
- increased BUN
- renal dysfunction
- Coagulation Factors
- possible coaguopath
- CBC
Patient labs:
- CBC shows Hgb of 6.8 g/dL
- normal platelets
- normal coagulation factors
- CMP unremarkable
Should we transfuse?
yes, will transfuse
if acute, it is actually probalby lower than that b/c will take time for dilution to occur
unremarkable CMP makes us question upper GI bled b/c do not have elevated BUN
What factors about this woman’s case would warrant ICU admission?
- over 60
- significant comorbid disease burden
- continued bleeding
- severe blood loss
After getting patient labs, what are the possible next step?
Patient labs:
- CBC shows Hgb of 6.8 g/dL
- normal platelets
- normal coagulation factors
- CMP unremarkable
- Endoscopy
- esophagogastroduodenoscopy
- looks at upper Gi
- colonoscopy
- looks at lower Gi
- push enteroscopy
- looks more at small bowel
- esophagogastroduodenoscopy
- angiography
- there is NO role for barium imaging studies in acute GI bleed
What percent of acute GI bleeds resolve spontaneously and not recur?
- 90%
- but localization is important for direct treatment, evaluation or rebleeding risk and tailored medical therapy
This is a positivie test for what?
blue = positive fecal occult test
which you would see with chronic GI bleed
What is the general presentation for a patient with a chronic GI bleed?
Outpatient or inpatient?
- Presentation
- no hemodynamic changes
- chronic anemia
- positive fecal occult blood test
- (?) melena
- (?) hematochezia
- may have very low hemoglobin, but hemodynamically stable
- iron deficiency anemia – look for low MCV
- Evaluation can proceed at a less urgent pace adn often on an outpatient basis
If no bleed is found in EGD or colonoscopy– think small bowel
What are the steps to a small bowel evaluation?
- radiographic with barium imaging
- CT or MR enterography
- Capsule endoscopy (swallow pill w/ camera)
- Push eteroscopy (can see whole bowel)
- Balloon enteroscopy
- Angiography (radio labeled blood)
- Laparotomy with endoscopy in OR
List the common presentations of Upper GI bleed.
- Above ligament of Treitz
- Hematemesis
- bright red or coffee grounds
- elena (blood in GI tract for >14 hrs)
- occasionally hematochezia
- elevated blood urea nitrogen (BUN)
- hyperactive bowel sounds
How can you tell if there is a high risk of bleeding or a low risk when doing an endoscopy on a patient with peptic ulcer disease?
- High risk
- visible vessel or active bleeding at endoscopy
- (treat endoscopically)
- high risk for re-bleed– most occurs w/in 1-2 days
- 1/3 will rebleed in 1-2 years
- Low risk
- clean based ulcer
- can be discharged same day
What are the caues of esophageal varices?
Treatment?
Continual recurrent bleeding?
- Causes
- cirrhosis and portal hypertension
- Treatment
- endoscopic ligation – suck up a bleb & put band around
- chronic beta blockers
- octreotide (if active bleed)
- sclerotherapy
- Recurrent bleeding despite the above: TIPS transjugular intrahepatic portosystemic shunt
- in those with advanced liver disease- connect portal vein to hepatic vein reducing back pressure causing
What are the causes of Mallory-Weiss tears?
location?
treatment?
- cause
- vomiting, retchign, coughing, associated with alcoholics
- often with associated hiatal hernia
- location
- most common ongastric side of GE junction
- Treatment
- usually spontaneous resolution (80-90%)
- if not injection like for PUD
What are the causes of Gastritis?
Which demographics should receive prophylaxis treatment?
What is the prophylactic treatment?
- Causes
- NSAIDS, EtOH, stress
- not a major cause of major GI bleed
- Prophylaxis with H2 blockers or PPI in critically ill reduces bleeding
- burns
- ventilated trauma
- intracranial disease
- coagulopathy
Symptoms & treatment esophageal cancer?
- Symptoms
- weight loss
- dysphasia that progresses over time
- Treatment
- chemotherapy
- surgery
- endoscopic palliative procedures
Symptoms & treatment gastric cancer?
- Symptoms
- early satiety
- weight loss
- abdominal pain
- Treatment
- surgery
- chemotherapy
How does Meckel’s Diverticulum present?
Diagnosis
Treatment?
- Bleeding into the stool in a young patient
- present in 2% of pop
- 2 feet proximal to ileocecal valve
- usually 2 in in length
- usually 2 years old at presentation
- history
- painless bleeding into stool in a young patient
- Diagnosis
- Meckel’s scan
- Treatment
- surgery
Symptoms and treatment of Hemorrhoids?
- Symptoms
- bleedign associated with a bowel movement
- Treatment
- supportive
- surgical or banding
Why do diverticuli happen?
Symptoms of diverticular bleeding?
Treatment?
- Vasa Recta
- small arteries that supply colonic mucosa
- penetrate the colon allowing muscular weakness
- increased pressure leads to diverticular development
- Symptoms
- painless
- often significant blood loss
- often R sided – even though you more often see diverticuli on the L side
- b/c on right side tend to be wider necks & domes & leave vasa recta more susceptible to injury
- abrupt onset
- Treatment
- 80% spontaneous resolution
- vasopressin
- embolization
- surgical resection
What is vascular ectasia?
It usually causes what type of GI bleed?
treatment?
- AKA
- angiodysplasia
- arteriovenous malformation, or angiomas
- usually occult bleeding
- treatment
- endoscopic hemostatic therapy
What is shown in the provided image?
symptoms?
treatment?
- Colon polyp
- usually asymptomatic
- treatment
- polypectomy
Symptoms of colon cancer?
Treatment?
- Symptoms
- weight loss
- anemia
- change in bowel havits
- Treatment
- surgical removal
Symptoms of Inflammatory bowel disease?
Treatment?
- Symptoms
- diarrhea
- abdominal pain
- colitis
- possible fever
- Treatment
- corticosteroids
- 5-ASA
- immunotherapy
