Tutorial 3: GI bleed, cirrhosis, acute abdo pain Flashcards
What is hematemesis?
vomiting of red blood and indicates upper GI bleeding
Usually from a peptic ulcer, vascular lesion, or varix.
What is coffee-ground emesis?
vomiting of dark brown, granular material that resembles coffee grounds.
It results from upper GI bleeding that has slowed or stopped, with conversion of red hemoglobin to brown hematin by gastric acid.
What is hematochezia?
passage of gross blood from the rectum and usually indicates lower GI bleeding but may result from vigorous upper GI bleeding with rapid transit of blood through the intestines.
What is melena?
black, tarry stool and typically indicates upper GI bleeding, but bleeding from a source in the small bowel or right colon may also be the cause.
How much blood is required to cause melena?
About 100 to 200 mL of blood in the upper GI tract i
What else can cause black stool? (not bleeding)
iron, bismuth, or various foods
How is chronic occult bleeding diagnosed?
can occur from anywhere in the GI tract and is detectable by chemical testing of a stool specimen.
Name common causes of upper GI tract bleeds
Duodenal ulcer (20–30%)
Gastric or duodenal erosions (20–30%)
Varices (15–20%)
Gastric ulcer (10–20%)
Mallory-Weiss tear (5–10%)
Erosive esophagitis (5–10%)
Angioma (5–10%)
Arteriovenous malformations (< 5%)
Gastrointestinal stromal tumors
Hemobilia
Name common causes of lower GI tract bleeds
Anal fissures
Angiodysplasia (vascular ectasia)
Colitis: Radiation, ischemic, infectious
Colonic carcinoma
Colonic polyps
Diverticular disease
Inflammatory bowel disease: Ulcerative proctitis/colitis, Crohn disease
Internal hemorrhoids
Name causes of small bowel lesions
Overall, rare.
Angiomas
Arteriovenous malformations
Meckel diverticulum
Tumors
Where is the division drawn between upper GI and lower GI?
above the ligament of Treitz
What drugs are associated with BI gleed?
anticoagulants (eg, heparin, warfarin)
those affecting platelet function (eg, aspirin and certain other nonsteroidal anti-inflammatory drugs [NSAIDs], clopidogrel, selective serotonin reuptake inhibitors [SSRIs])
and those affecting mucosal defenses (eg, NSAIDs).
What comorbidities directly make GI bleeds more likely?
chronic liver disease (eg, alcoholic liver disease, chronic hepatitis)
hereditary coagulation disorders
What makes taking a history of GI bleed difficult, and how should you get around it?
even small amounts (5 to 10 mL) of blood turn water in a toilet bowl an opaque red, and modest amounts of vomited blood appear huge to an anxious patient.
However, most can distinguish between blood streaks, a few teaspoons, and clots.
What should you ask a pt about their hematemesis?
whether blood was passed with initial vomiting or only after an initial (or several) nonbloody emesis
specific questions to distinguish between hematemesis and hemoptysis (pts confuse them)
What should you ask a pt about their rectal bleeding?
whether pure blood was passed; whether it was mixed with stool, pus, or mucus; or whether blood simply coated the stool or toilet paper
What history should you ask about for a pt with bloody diarrhea?
travel or other possible exposure to GI pathogens.
What should you make sure to include in your ROS for GI bleed?
abdominal discomfort
weight loss
easy bleeding or bruising
previous colonoscopy or endoscopy results
symptoms of anemia (eg, weakness, easy fatigability, dizziness).
What PMHX should be elicited for GI bleeds?
previous GI bleeding (diagnosed or undiagnosed); known inflammatory bowel disease, bleeding diatheses, and liver disease; and use of any drugs that increase the likelihood of bleeding or chronic liver disease (eg, alcohol).
What does the physical exam focus on for GI bleed?
vital signs and other indicators of shock or hypovolemia
anemia
What other physical exam findings should you look for?
External stigmata of bleeding disorders (eg, petechiae, ecchymoses)
Signs of chronic liver disease (eg, spider angiomas, ascites, palmar erythema)
Signs of portal hypertension (eg, splenomegaly, dilated abdominal wall veins).
What physical exam component is necessary?
DRE: stool color, masses, fissures
Consider anoscopy to Dx hemorrhoids
Occult blood test
List red flag signs for hypovolemia or hemorrhagic shock
Syncope Hypotension Pallor Diaphoresis Tachycardia
Suspicion of bleed + … Epigastric abdominal discomfort relieved by food or antacids suggests…
Peptic ulcer disease
However, many pt with bleeding ulcers don’t have pain
Suspicion of bleed + … A history of cirrhosis or chronic hepatitis
suggests
Esophageal varices
Suspicion of bleed + dysphagia
suggests
esophageal cancer
stricture
Suspicion of bleed +
Vomiting and retching before the onset of bleeding
suggests
Mallory weiss tear
although about 50% of patients with Mallory-Weiss tears do not have this history.
Suspicion of bleed + Hx of bleeding (eg, purpura, ecchymosis, hematuria)
suggests
bleeding diathesis
eg, hemophilia, hepatic failure
Bloody diarrhea, fever, and abdominal pain suggest
ischemic colitis
inflammatory bowel disease (eg, ulcerative colitis, Crohn disease)
infectious colitis (eg, Shigella, Salmonella, Campylobacter, amebiasis)
Hematochezia suggests…
diverticulosis or angiodysplasia
Fresh blood only on toilet paper or the surface of formed stools suggests
internal hemorrhoids or fissures,
blood mixed with the stool suggests
more proximal source
Occult blood in the stool may be the first sign of colon cancer or a polyp, particularly in patients > 45 years.
Arteriovenous malformations, especially of the mucous membranes, suggest
hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome).
Cutaneous nail bed and GI telangiectasia may indicate
systemic sclerosis or mixed connective tissue disease.
Spider angiomas, hepatosplenomegaly, or ascites is consistent with …
chronic liver disease and hence possible esophageal varices.
When should a CBC be performed?
patients with large-volume or occult blood loss
Ix for patients with more significant bleeding
coagulation studies (eg, platelet count, PT, PTT)
liver tests (eg, bilirubin, alkaline phosphatase, albumin, AST, ALT).
How often do you repeat Hb and Hct in a pt with severe bleeding?
up to every 6h
If bleeding is ongoing, what test should you consider?
Type and cross match
What diagnostic tests are done in pt with suspected upper GI bleed? lower GI bleed?
Nasogastric tube (NGT) for all but those with minimal rectal bleeding
Upper endoscopy for suspected upper GI bleeding
Colonoscopy for lower GI bleeding (unless clearly caused by hemorrhoids)
What test should be done in all patients with suspected upper GI bleeding (eg, hematemesis, coffee-ground emesis, melena, massive rectal bleeding)
NG aspiration and lavage
Left in place to monitor continuing or recurrent bleeding
Removed if no sign of bleeding and only bile returned
When should endoscopy be done rapidly vs deferred?
should be done rapidly for significant bleeding but may be deferred for 24 hours if bleeding stops or is minimal
Can be therapeutic in addition to diagnostic
What test should you not do in acute GI bleeding?
Upper GI barium x-rays have no role in acute bleeding, and the contrast used may obscure subsequent attempts at angiography.
What are the advantages of angiography in acute bleeding?
useful in the diagnosis of upper GI bleeding and permits certain therapeutic maneuvers (eg, embolization, vasoconstrictor infusion)
When should pt have colonoscopy?
patients with hematochezia, whose symptoms are not consistent for simple hemorrhoids
What rapid prep can be given for pt who have significant lower GI bleed?
5 to 6 L of polyethylene glycol solution delivered via NGT or by mouth over 3 to 4 hours
If bleeding is rapid and colonoscopy can’t visualize, what test can be done?
angiography
Bleeding should be > 0.5 to 1 mL/minute
What is the preferred diagnostic method for occult GI bleed?
Endoscopy, with symptoms determining whether the upper or lower GI tract is examined first.
What can be used to diagnose occult bleeding in the lower GI tract if colonoscopy is not an option?
Double-contrast barium enema and sigmoidoscopy can be used for the lower tract when colonoscopy is unavailable or the patient refuses it.
What tests should be considered If the results of upper endoscopy and colonoscopy are negative and occult blood persists in the stool?
upper GI series with small-bowel follow-through
CT enterography
small-bowel endoscopy (enteroscopy)
capsule endoscopy (which uses a small pill-like camera that is swallowed)
technetium-labeled colloid or red blood cell (RBC) scan
angiography
What is the treatment for acute GI bleed?
Secure airway if needed IV fluid resuscitation Blood transfusion if needed Sometimes drugs In some, endoscopic or angiographic hemostasis
Why is airway particularly important in GI bleed?
A major cause of morbidity and mortality in patients with active upper GI bleeding is aspiration of blood with subsequent respiratory compromise.
What therapy is initiated immediately for pt with GI bleed?
IV fluids are initiated immediately, as for any patient with hypovolemia or hemorrhagic shock
Healthy adults are given normal saline IV in 500- to 1000-mL aliquots until signs of hypovolemia remit—up to a maximum of 2 L
When should you transfuse?
Requiring further rescusc after fluids
Older folks: transfuse to Hct .30
Younger pt or chronic bleed: wait till Hct < 0.23 or SSx like dyspnea, coronary ischemia
What other blood product must be monitored closely?
Platelets:
- platelet transfusion may be required with severe bleeding.
- Patients who are taking antiplatelet drugs (eg, clopidogrel, aspirin) have platelet dysfunction, often resulting in increased bleeding.
What should you do if a pt is taking antiplatelet drug or anticoagulant for recent CV indication?
Consult cardiologist prior to stopping the drug, reversing the drug, or giving a platelet transfusion.
If large blood transfusion required, what should be given?
Packed RBCs, fresh frozen plasma, and platelets
Consider correction with FFP or prothrombin complex
