Upper And Lower GI Bleeding

Question 1

GI bleeding=

Answer 1

Refers to any bleeding that starts in the GIT

-divided into upper ( esophagus , stomach and duodenum) and lower ( small and large intestine rectum and anus)

Question 2

Acute vs chronic bleeding signs :

Answer 2

Acute= may include weakness, dizziness , shortness of breath, abdominal pain and cramping and /or diarrhea
Chronic= fatigue, lethargy , shortness of breath and can also lead to anemia

Question 3

Major presenting factors of upper GI bleeding:

*Upper GI bleeding 5 times more common than lower

Answer 3

1) hematemesis - suggests bleeding proximal to the ligament of treitz
2) Melena (90% of cases) from upper GI bleeding 
3) hematochezia -10% of cases are from upper GI bleeding

Question 4

Severity of bleeding the amount of blood loss:

Answer 4

🔸minor= <10% of intravascular volume —> hemodynamically normal 
🔸moderate= 10-20% —> orthostatic hypotension or tachycardia
🔸massive= 20-25%—> shock

Question 5

Classification of blood loss :

Answer 5

🔸class 1: up to 750ml 
🔸class2: 750-1500
🔸class 3: 1500-2000
🔸class4: >2000

Question 6

Upper GI bleeding diagnosis is mainly related to :

Answer 6

▪️peptic ulcer disease

▪️portal hypertension

Question 7

We transfuse blood in:

Answer 7

Hemodynamically unstable pts , any signs of poor tissue oxygenation, continued bleeding , persistent low Hct level
* blood test should be done: INR, PTT
🔸O(-) full cross match : is an option for blood transfusion

Question 8

What is a unit of packed cell?

Answer 8

▪️250ml volume
▪️contains citrate (anticoagulant) and preservative
▪️1unit of packed cells will⬆️ the Hb concentration by approx. 0.5mg/dL

Question 9

What means massive transfusion?

Answer 9

More than 1 blood volume ( 10units) transfused in 24 hrs

-may dilute platelets and clotting factors

Question 10

Treatment of dilution coagulopathy?

Answer 10

✅plasma/Fresh frozen plasma 10-15 mL/kg
Usual adults dose 2 units
- 5-8ml /kg dose for warfarin reversal
✅platelets -keep the count greater than 50,000 in the bleeding pt
- 1unit should increase the count by 5,000-10,000
Dose: 6pack

Question 11

In massive transfusion so parameters may go wrong ?!:

Answer 11

1) hypothermia
2) potassium
3) citrate toxicity ( hypocalcemia )

Question 12

Upper GI bleeding etiology:

Answer 12

🔸peptic ulcer 50%
🔸gastritis 20%
🔸esophageal varices 10%
The rest : tears , AVM, CA…20%

Question 13

Things could be done before endoscopy for GI bleeding;

Answer 13

1) NG lavage - 15-20% of UGIB have negative aspirate
2) Drug
3) ABC
4) patient and family consent

Question 14

Endoscopy:

Diagnostic , prognostic , therapeutic

Answer 14

We can see :

• active vessel bleeding
• non bleeding visible vessel
• adherent clot
• flat spot
• clean base

Question 15

Peptic ulcer bleeding treatment:

Answer 15

✅PPI’s
-raise gastric PH
-better platelet activity
-pepsinogen requires acid to become activated to pepsin
*high risk pts: elderly, co-morbidity, more severe bleeding
✅somatostatin/octreotide

Question 16

Surgery in GI 🩸 bleeding:

Answer 16

▪️hemodynamically instability despite vigorous resuscitation (more than3 unit transfusion)
▪️recurrent hemorrhage after initial stabilization
▪️shock associated with recurrent hemorrhage
▪️continued slow bleeding with a transfusion requirement exceeding 3 units per day

Question 17

Pharmacological treatment :

Answer 17

Drug of choice:
✅Glypressin (terlipressin) - control bleeding and reduce mortality rate
- analouge of vasopressin ( management of low bp)
✅sandostatin
✅pitressin

Question 18

After endoscopic treatment that failed to achieve hemostasis or rebleeding?

Answer 18

✅balloon tamponade - is an effective way to achieve temporary hemostasis from bleeding esophagogastric varices (s-B tube ) , complications-> aspiration, perforation of esophagus
✅transjugular intrahepatic protosystemic shunt
✅surgery for shunt

Question 19

Ulcers causes:

Answer 19

🔸idiopathic
🔸drug induced: aspirin NSAIDs drugs 
🔸infections : H. Pylori, cytomegalovirus, Herpes simplex virus 
🔸stress induced ulcer 
🔸zollinger ellison syndrome

Question 20

Portal hypertension- varices :

Answer 20

▪️esophageal varices
▪️gastric varices 
▪️duodenal varices 
▪️portal hypertensive gastropathy
▪️cirrhosis

Question 21

Gastritis causes :

Answer 21

1) NSAIDs and other drugs
2) infections
3) crohn’s disease
4) illness and injuries

Question 22

Esophagitis causes :

Answer 22

1) peptic
2) infections
3) pill-induced: alendronate, tetracycline, quinidine, potassium chloride , aspirin NSAIDs

Question 23

Lower GI bleeding :

Answer 23

🔸hematochezia 90%

🔸melena 10%

Question 24

Etiology of lower GI bleed:

Answer 24

Diverticulitis 
Angiodysplasia 
CA
Colitis 
Ischemia 
Hemorrhoids

Question 25

Lower GI bleed:

Answer 25

Usually painless

If painful-> mesenteric ischemia

Question 26

Investigation of the lower GI bleed :

Answer 26

🔸-CBC
-BUN
-Creatinine 
-INR
-PTT 
-T/S
🔸plain x ray and abd. CT

Question 27

Diagnostic procedure for lower Gi bleed :

Answer 27

▪️endoscopy 80% accuracy
▪️angiography
▪️rbcs scans

Question 28

Major causes of LGIB:

Answer 28

1) diverticulitis
2) Ischemia
3) Anorectal (hemorrhoids, fissures, rectal ulcera)
4) neoplasia (polyps and cancers)
5) angiodysplasia
6) postpolypectomy
7) inflamm. Bowel disease
8) radiation colitis
9) other colitis
10) small bowel/ upper GIB
11) other causes or unknown causes

Question 29

Major presenting factors and symptoms of LGIB:

Answer 29

• black or tarry stool
• Dark blood mixed with stool
• stool mixed or coated with bright red blood

Question 30

Diverticular disease :

Answer 30

• results from progressive injury to the artery supplying that segment
• as diverticulum herniates , the penetrating vessel responsible for the wall weakness at that point becomes draped over the dome of the bowel lumen only by mucosa

Question 31

Colitis :

Answer 31

✅Inflammatory: crohn’s disease 
✅infectious : C diff
✅collagenous: lymphocytic 
✅colonic ischemia 
✅diversion colitis : segment lacks short chain fa’s

Question 32

Hemorrhoids :

Answer 32

External= arise from the inferior hemorrhoidal plexus and are located beneath the dentate line. 
Internal= arise from the superior hemorrhoidal cushion. Their three primary locations correspond to the end branches of the middle and superior hemorrhoidal veins

Question 33

Anal fissures :

Answer 33

-tear in the lining of the anal canal distal to the dentate line , which most commonly occurs in the posterior midline
-most of the fissures are caused by local trauma
- seen in crohn’s disease , leukemia and tuberculosis
Medical therapy:
✅topical nitroglycerine
✅botulinum toxin
✅oral nifedipine/ diltiazem
✅topical diltiazem/ bethanechol
✅surgical intervention ( lateral sphincterotomy/ incontinence)

Question 34

Angiodysplasia:

Answer 34

-most common vascular anomaly of the GIT
-vascular tumors or angiomas, vascular anomalies associated with congenital or systemic diseases , acquired or sporadic lesions
▪️most prominent feature is the presence of dilated , tortuous submucosal veins

Question 35

Polyps:

Answer 35

Hyperplastic polyps 
Adenomatous polyps 
Tubular polyps 
Peutz jegher 
Familiar polyposis