Thackeray: Upper GI Bleeds

Question 1

How do you identify a pt w/ an upper GI bleed?

Answer 1

1. GI blood loss (hematochezia- blood rectum, melena- slowly blood stool, hematemesis, volume loss)
2. Obscure signs of GI bleeding not seen directly (IDA, fatigue, pale, dypsnea, angina)

Question 2

How do you manage a pt w/ an upper GI bleed?**

Answer 2

INITITAL ASSESSMENT AND RESUSCITATION***

1. ABCs (airway, CPR)
2. IV access (2 large bore IVs–give volume back)
3. Infusion (crystalloid, blood products)

SECONDARY ASSESSMENT

1. lab studies (Hb 13 vs 6)
2. Underlying pt conditions (severe cardiac disease- can’t afford Hb of 6, liver disease, coagulopathy)
3. monitor vital signs
4. determine appropriate level of care (hospital vs home, ICU vs floor)

Question 3

What are common and uncommon causes of upper intestinal bleeding?

Answer 3

Common: esophagus, stomach, small bowel

Uncommon: bile ducts, liver, pancreas

Question 4

What is the test of choice for diagnosing an upper GI bleed?

Answer 4

Upper endoscopy (EGD= esophagogastroduodenoscopy)

Question 5

What are common causes of esophageal bleeding?

Answer 5

VARICES**
esophagitis
mallory weiss tear
tumors

Question 6

**An alcoholic presents with dramatic bleeding and hematemesis.

Answer 6

Varices** are associated w/ liver disease and cirrhosis, which would both BLOCK blood from returning to the IVC leading to portal hypertension.

Blood then is pushed back through the hepatic portal vein to the left gastric vein and can cause esophageal varices!

Question 7

How do you treat varices?

Answer 7

Octreotide or Vasopressin
Proton Pump inhibitor (decrease acid levels)
Non-selective Beta-blocker (decrease systemic pressure)
Variceal band ligation
TIPS/Surgical shunt

Question 8

A pt presents w/ odynophagia, dysphagia, hematemesis.

Answer 8

Esophagitis (inflammation of the stomach) is either caused by acid exposure or things getting stuck in the esophagus (pill impaction or food impaction)

It’s associated w/ REFLUX cause then you’re getting a helluva lotta acid exposure.

Question 9

How do you tx esophagitis?

Answer 9

Decrease the acid or make sure things don’t get stuck!

PPI
lifestyle modification (less acid coming back into the esophagus)
soft diet

Question 10

A young college student who has been vomiting/retching b/c they’re hung over presents w/ hematemesis and odynophagia.

Answer 10

Mallory Weiss Tear is a small mucosal tear that usually occurs at the gastro esophageal junction.

Question 11

How do you tx a Mallory Weiss Tear?

Answer 11

Usually stops spontaneously

PPI

Question 12

What are common causes of stomach bleeding?

Answer 12

ULCERS*
gastritis
vascular ectasis
dieulafoy lesions
varices
tumors

Question 13

What is an ulcer?

Answer 13

break in the mucosa WITH DEPTH, may involve the submucosa

Question 14

What is an erosion?

Answer 14

scarping the skin

break in the mucosa WITHOUT DEPTH

Question 15

What is peptic ulcer disease?

Answer 15

ulcer or erosion in the stomach or duodenum

Question 16

What are RF/main causes of peptic ulcer disease?

Answer 16

1. H. pylori** (x4)

2. NSAIDS ** (x3)

Question 17

How do you treat peptic ulcer disease caused by h. pylori?**

Answer 17

Treatment usually lasts for 2 weeks, and then you should test to make sure that it’s been eradicated (breath or stool)**. If it fails it’s usually d/t noncompliance.

Triple therapy (2 ABs + PPI)= clarithro+ amox+ PPI

Quadruple tx (2 ABS + bismuth + PPI)

Question 18

How do NSAIDS cause peptic ulcer disease?

Answer 18

PGs in the gut regulate mucus and bicarb secretion. NSAIDS inhibit COX and decrease PG production

Question 19

A pt presents with a burning epigastric pain that is worse with eating. As well as belching, bloating, nausea and feelings of early satiety.

Answer 19

Gastric ulcer

Question 20

A pt presents with burning epigastric pain that improves w/ eating?

Answer 20

duodenal ulcer

Question 21

How do you treat a young pt w/ a peptic ulcer who doesn’t have alarming symptoms

Answer 21

trial of empiric anti-ulcer therapy with close follow up

non-invasive testing for H.pylori and treatment when appropriate (serology, breath, stool)

definitive diagnostic eval (imaging/endoscopy)

Question 22

What is vascular ectasis?

Answer 22

superficial blood vessels that can bleed

Question 23

What is a dieulafoy lesions?

Answer 23

submucosal artery that can bleed (someone who comes in bleeding over and over)

Question 24

What are common cuases of duodenal bleeding

Answer 24

ulcers

vascular malformations- arteries and veins that connect come to surface of bowel–clip–destroy vessel

tumors

Question 25

What are common causes of lower GI bleeding?

Answer 25

Diverticular bleed
Tumor
Vascular Malformation
Post-polypectomy
Ulcer