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Internal Medicine > Symptom to Diagnosis - GI Bleeding > Flashcards

Symptom to Diagnosis - GI Bleeding Flashcards

1
Q

How can we clinically assess the volume status?

A

Signs of shock –> 30-40% volume depletion.
Orthostasis –> 20-25% volume depletion.
Tachycardia –> 15% volume depletion.

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2
Q

How do we calculate necessary replacement?

A

Weight in kg x 0.6 x % volume depletion.

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3
Q

What do we do to be ready for further bleeding?

A
  1. All patients should have their blood typed and cross-matched for at least 2 units.
  2. Patients may INITIALLY have normal Hcts that drop after fluid replacement.
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4
Q

Can we diagnose anemia through the physical exam?

A

No, it is insensitive.

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5
Q

In large bleeds, what can help monitor the fluid status?

A

A Foley catheter.

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6
Q

What initial diagnostic tests should be ordered?

A
  1. CBC + Platelet count.
  2. Basic metabolic panel (chem-7)
  3. LFTs
  4. PT, PTT
  5. Upright CXR
  6. Possibly NG tube placement –> may help localize source and acuity of blood loss.
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7
Q

Mention the common causes of upper GI bleeding.

A
  1. PUD
  2. Varices
  3. Mallory-Weiss tear
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8
Q

Mention less common causes of upper GI bleeding.

A
  1. Angiodysplasia
  2. Gastritis
  3. Malignancy
  4. Esophagitis
  5. Dieulafoy lesions
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9
Q

Mention common causes of lower GI bleeding.

A
  1. Diverticulosis
  2. Malignancy or polyp
  3. Colitis (inflammatory/ infectious/ ischemic)
  4. Angiodysplasia
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10
Q

Mention less common causes of SMALL BOWEL bleeding.

A
  1. Angiodysplasia
  2. Ulcers
  3. Malignancy
  4. Crohn disease
  5. Meckel diverticulum
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11
Q

Mention the 2 MCC of anorectal bleeding.

A
  1. Hemorrhoids

2. Anal fissures

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12
Q

What are the clinical clues for diverticular bleed?

A
  1. Brisk self-limited bleeds

2. History of diverticuli

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13
Q

What are the clinical clues of angiodysplasia?

A
  1. Brisk lower GI bleedings

2. More common with END-STAGE RENAL DISEASE!

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14
Q

What are the clinical clues of PUD?

A
  1. Often asymptomatic.

2. May present with epigastric pain or weight loss.

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15
Q

What are the clinical clues of colon cancer?

A
  1. History of anemia.

2. Changing bowel habits.

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16
Q

What is important to keep in mind about blood?

A

IT IS CATHARTIC!

A brisk bleed from the upper source can present with bright red blood per rectum.

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17
Q

What is the risk of diverticular hemorrhage in a patient with diverticuli?

A

Not known - Estimated 3-15%.

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18
Q

Left- or right-sided diverticuli seem to cause the heaviest bleedings?

A

RIGHT-SIDED, even though left-sided diverticuli are more common.

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19
Q

What is the rule about diverticular hemorrhage?

A

Spontaneous cessation - moderate blood loss (75%).

Recurrence is common (40%)

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20
Q

Diverticular hemorrhage carries a good or a poor prognosis?

A

A POOR prognosis.

Although diverticular hemorrhage seldom causes death, it is a marker for a relatively poor, short-term prognosis.

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21
Q

What historical feature suggests PUD?

A

NSAID use.

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22
Q

What historical feature suggests ischemic colitis?

A

Severe vascular disease.

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23
Q

What historical feature suggests radiation colitis?

A

Pelvic radiation.

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24
Q

What historical feature suggests infectious colitis?

A

Febrile illness.

25
Q

What historical feature suggests aortoenteric fistula (duodenal MC)?

A

Aortic graft.

26
Q

What historical feature suggests esophageal varices?

A

Liver disease or alcohol history.

27
Q

What historical feature suggests Mallory-Weiss tear?

A

Retching preceding hematemesis.

28
Q

What historical feature suggests post polypectomy bleeding?

A

Recent colonic polypectomy.

29
Q

What historical feature suggests stercoral ulcer?

A

Severe constipation.

30
Q

Mention some features that suggest upper GI bleeding.

A
  1. Nausea and vomiting.
  2. Hematemesis or coffee-ground emesis
  3. Melena
  4. BUN/Cr >30
31
Q

Mention some features that suggest lower GI bleeding.

A
  1. Hematochezia

2. 10-15% of patients with hematochezia have an upper GI source –> Older patients with duodenal ulcers.

32
Q

How can the physical exam aid in the localization of GI bleeding?

A
  1. Look for stigmata of chronic liver disease, cancer-related cachexia, or extraintestinal manifestations of IBD.
  2. Patients who are volume-depleted, orthostatic, or hypotensive are about twice as likely to have an UPPER GI bleed, than a lower one.
33
Q

Angiography requires bleeding at what rate to detect ACTIVE bleeding?

A

0.5mL/min.

34
Q

Where is angiography useful in diverticular bleeding?

A

At localization the site of bleeding before surgery.

35
Q

When do we initiate transfusion?

A

When Hct 30% (1L).

36
Q

What does the management of diverticular disease involve?

A
  1. Specific treatment is seldom necessary because most diverticular hemorrhages stop spontaneously.
  2. Endoscopic treatment, primarily clipping but also thermoregulation or sclerotherapy, is occasionally used.
  3. Angiographic intervention, with vasoconstrictor agents or embolization, can also be used.
37
Q

What percentage of patients over 60 have angiodysplasia?

A

<5%.

38
Q

What is important to bury in mind about angiodysplasia?

A

It is a common cause of bleeding in patients with END-STAGE RENAL DISEASE!

39
Q

What is the textbook presentation of colon cancer?

A

Iron def. anemia + constipation in a middle-aged patient.

Physical exam may reveal anemia and fullness in the LLQ.

40
Q

Unlike colon cancer, colonic polyps are an unlikely source of acute bleeding. They are most likely to bleed when they are removed. How often does this happen?

A

1/200 polypectomies.

41
Q

What are the clinical clues of PUD?

A
  1. Abdominal pain
  2. NSAID use
  3. Relationship to eating
42
Q

What is the clinical clue of gastritis?

A

Often asymptomatic prior to hemorrhage.

43
Q

What are the clinical clues of esophageal varices?

A
  1. History of portal HTN

2. Stigmata of chronic liver disease

44
Q

What are the clinical clues of Mallory-Weiss tear?

A

Hematemesis preceded by vomiting, especially with retching.

45
Q

What is the textbook presentation of esophageal varices hemorrhage?

A
  1. Patient with known cirrhosis presents with heavy upper GI bleeding (hematemesis or melena).
  2. Stigmata of chronic liver disease + frequently a history of previous hemorrhages.
  3. Lab data demonstrate LFTs consistent with cirrhosis and thrombocytopenia.
46
Q

What must be the portal pressure for esophageal varices to occur?

A

Must exceed 12mmHg.

47
Q

What percentage of patients with cirrhosis have esophageal varices?

A

50%.

48
Q

What is the system that classifies the severity of cirrhosis?

A

The Child-Turcotte-Pugh system.

49
Q

What does Child-Turcotte-Pugh system take into account?

A
  1. Presence of encephalopathy
  2. Ascites
  3. Hyperbilirubinemia
  4. Hypoalbuminemia
  5. Clotting deficiency
50
Q

What percentage of Child-Turcotte-Pugh grade A disease have varices and what percentage of grade C?

A

Grade A –> 40%.

Grade C –> 85%.

51
Q

What percentage of patients with varices will experience hemorrhage?

A

Approx. 33%.

52
Q

What is the prognosis of varices?

A

THE WORST OF GI BLEEDS.

33% die instantaneously.

53
Q

What percentage of survivors have recurrent bleeding in their 1st year?

A

Up to 70%.

54
Q

What is the 1-year mortality of a variceal bleed?

A

32-80%.

55
Q

What is the gold standard for diagnosis of varices?

A

Endoscopy.

56
Q

What should be given as soon as variceal hemorrhage is suspected?

A

IV octreotide –> Achieves cessation of variceal bleeding in about 80% of patients.

57
Q

Do we give antibiotics in variceal bleed?

A

Yes - 7-day norfloxacin –> Cirrhotic patients with upper GI bleed are at high risk for bacterial infections.
–> Decr. BOTH rate of bacterial infection + mortality.

58
Q

What is the 1st step in management of GI bleeding?

A

Patient hemodynamic stabilization, preparation must be made in case of further bleeding - Precedes diagnosis.

Internal Medicine (106 decks)

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