Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

IM Internal Med > Tutorial 3: GI bleed, cirrhosis, acute abdo pain > Flashcards

Tutorial 3: GI bleed, cirrhosis, acute abdo pain Flashcards

1
Q

What is hematemesis?

A

vomiting of red blood and indicates upper GI bleeding

Usually from a peptic ulcer, vascular lesion, or varix.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is coffee-ground emesis?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is hematochezia?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is melena?

A

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 well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How much blood is required to cause melena?

A

About 100 to 200 mL of blood in the upper GI tract i

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What else can cause black stool? (not bleeding)

A

iron, bismuth, or various foods

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How is chronic occult bleeding diagnosed?

A

can occur from anywhere in the GI tract and is detectable by chemical testing of a stool specimen.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Name common causes of upper GI tract bleeds

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Name common causes of lower GI tract bleeds

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Name causes of small bowel lesions

A

Overall, rare.

Angiomas

Arteriovenous malformations

Meckel diverticulum

Tumors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Where is the division drawn between upper GI and lower GI?

A

above the ligament of Treitz

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What drugs are associated with BI gleed?

A

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).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What comorbidities directly make GI bleeds more likely?

A

chronic liver disease (eg, alcoholic liver disease, chronic hepatitis)

hereditary coagulation disorders

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What makes taking a history of GI bleed difficult, and how should you get around it?

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What should you ask a pt about their hematemesis?

A

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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What should you ask a pt about their rectal bleeding?

A

whether pure blood was passed; whether it was mixed with stool, pus, or mucus; or whether blood simply coated the stool or toilet paper

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What history should you ask about for a pt with bloody diarrhea?

A

travel or other possible exposure to GI pathogens.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What should you make sure to include in your ROS for GI bleed?

A

abdominal discomfort
weight loss
easy bleeding or bruising
previous colonoscopy or endoscopy results

symptoms of anemia (eg, weakness, easy fatigability, dizziness).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What PMHX should be elicited for GI bleeds?

A

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).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What does the physical exam focus on for GI bleed?

A

vital signs and other indicators of shock or hypovolemia

anemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What other physical exam findings should you look for?

A

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).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What physical exam component is necessary?

A

DRE: stool color, masses, fissures

Consider anoscopy to Dx hemorrhoids

Occult blood test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

List red flag signs for hypovolemia or hemorrhagic shock

A 
Syncope
Hypotension
Pallor
Diaphoresis
Tachycardia
24
Q

Suspicion of bleed + … Epigastric abdominal discomfort relieved by food or antacids suggests…

A

Peptic ulcer disease

However, many pt with bleeding ulcers don’t have pain

25
Q

Suspicion of bleed + … A history of cirrhosis or chronic hepatitis
suggests

A

Esophageal varices

26
Q

Suspicion of bleed + dysphagia

suggests

A

esophageal cancer

stricture

27
Q

Suspicion of bleed +
Vomiting and retching before the onset of bleeding
suggests

A

Mallory weiss tear

although about 50% of patients with Mallory-Weiss tears do not have this history.

28
Q

Suspicion of bleed + Hx of bleeding (eg, purpura, ecchymosis, hematuria)
suggests

A

bleeding diathesis

eg, hemophilia, hepatic failure

29
Q

Bloody diarrhea, fever, and abdominal pain suggest

A

ischemic colitis

inflammatory bowel disease (eg, ulcerative colitis, Crohn disease)

infectious colitis (eg, Shigella, Salmonella, Campylobacter, amebiasis)

30
Q

Hematochezia suggests…

A

diverticulosis or angiodysplasia

31
Q

Fresh blood only on toilet paper or the surface of formed stools suggests

A

internal hemorrhoids or fissures,

32
Q

blood mixed with the stool suggests

A

more proximal source

Occult blood in the stool may be the first sign of colon cancer or a polyp, particularly in patients > 45 years.

33
Q

Arteriovenous malformations, especially of the mucous membranes, suggest

A

hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome).

34
Q

Cutaneous nail bed and GI telangiectasia may indicate

A

systemic sclerosis or mixed connective tissue disease.

35
Q

Spider angiomas, hepatosplenomegaly, or ascites is consistent with …

A

chronic liver disease and hence possible esophageal varices.

36
Q

When should a CBC be performed?

A

patients with large-volume or occult blood loss

37
Q

Ix for patients with more significant bleeding

A

coagulation studies (eg, platelet count, PT, PTT)

liver tests (eg, bilirubin, alkaline phosphatase, albumin, AST, ALT).

38
Q

How often do you repeat Hb and Hct in a pt with severe bleeding?

A

up to every 6h

39
Q

If bleeding is ongoing, what test should you consider?

A

Type and cross match

40
Q

What diagnostic tests are done in pt with suspected upper GI bleed? lower GI bleed?

A

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)

41
Q

What test should be done in all patients with suspected upper GI bleeding (eg, hematemesis, coffee-ground emesis, melena, massive rectal bleeding)

A

NG aspiration and lavage

Left in place to monitor continuing or recurrent bleeding

Removed if no sign of bleeding and only bile returned

42
Q

When should endoscopy be done rapidly vs deferred?

A

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

43
Q

What test should you not do in acute GI bleeding?

A

Upper GI barium x-rays have no role in acute bleeding, and the contrast used may obscure subsequent attempts at angiography.

44
Q

What are the advantages of angiography in acute bleeding?

A

useful in the diagnosis of upper GI bleeding and permits certain therapeutic maneuvers (eg, embolization, vasoconstrictor infusion)

45
Q

When should pt have colonoscopy?

A

patients with hematochezia, whose symptoms are not consistent for simple hemorrhoids

46
Q

What rapid prep can be given for pt who have significant lower GI bleed?

A

5 to 6 L of polyethylene glycol solution delivered via NGT or by mouth over 3 to 4 hours

47
Q

If bleeding is rapid and colonoscopy can’t visualize, what test can be done?

A

angiography

Bleeding should be > 0.5 to 1 mL/minute

48
Q

What is the preferred diagnostic method for occult GI bleed?

A

Endoscopy, with symptoms determining whether the upper or lower GI tract is examined first.

49
Q

What can be used to diagnose occult bleeding in the lower GI tract if colonoscopy is not an option?

A

Double-contrast barium enema and sigmoidoscopy can be used for the lower tract when colonoscopy is unavailable or the patient refuses it.

50
Q

What tests should be considered If the results of upper endoscopy and colonoscopy are negative and occult blood persists in the stool?

A

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

51
Q

What is the treatment for acute GI bleed?

A 
Secure airway if needed
IV fluid resuscitation
Blood transfusion if needed
Sometimes drugs
In some, endoscopic or angiographic hemostasis
52
Q

Why is airway particularly important in GI bleed?

A

A major cause of morbidity and mortality in patients with active upper GI bleeding is aspiration of blood with subsequent respiratory compromise.

53
Q

What therapy is initiated immediately for pt with GI bleed?

A

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

54
Q

When should you transfuse?

A

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

55
Q

What other blood product must be monitored closely?

A

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.
56
Q

What should you do if a pt is taking antiplatelet drug or anticoagulant for recent CV indication?

A

Consult cardiologist prior to stopping the drug, reversing the drug, or giving a platelet transfusion.

57
Q

If large blood transfusion required, what should be given?

A

Packed RBCs, fresh frozen plasma, and platelets

Consider correction with FFP or prothrombin complex

IM Internal Med (11 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions