upper GI bleed HYHO Flashcards
what is the landmark of a UGI bleed?
from a source above the ligament of Treitz
The suspensory ligament of the duodenum
hypovolemic shock
inadequate circulating blood volume detected by the baroreceptor reflex
triggers increase heart rate and sympathetic stimulation with vasoconstriction of nonessential
organs. Blood is redirected away from skin, skeletal muscle, and the splanchnic circulation.
Patient appears cold, clammy and vasoconstricted. Signs of shock may appear with 30-40%
volume loss.
Peptic ulcer: symptoms
Upper abdominal pain
Esophageal ulcer symptoms :
Odynophagia, gastroesophageal reflux, dysphagia
Mallory-Weiss tear symptoms
Emesis, retching, or coughing prior to hematemesis
Variceal hemorrhage or portal hypertensive gastropathy: symptoms
Jaundice, abdominal
distention (ascites).
Bleeding from esophagogastric varcies is the single most life-
threatening complication of portal hypertension. It is responsible for 1/3 of all deaths in patients with cirrhosis.
Malignancy symptoms
Dysphagia, early satiety, involuntary weight loss, cachexia
what meds may cause peptic ulcer formation?
aspirin and other NSAIDS (ibuprofen, naproxen sodium, etc.)
what meds promote bleeding?
as antiplatelet agents (clopidogrel) and anticoagulants (warfarin)
what meds can turn stool black?
bismuth (pepto-bismol) and iron,
what should you check for in PE for UGI bleed?
x Vital signs (hemodynamic compromise , signs of shock)
x Confusion (may indicate lack of blood flow/oxygen to brain)
x Peripheral vasoconstriction—cool extremities, cyanosis
x Signs of liver disease (jaundice, ascites, caput medusa)
what labs should you get for UGI bleed?
x Complete blood count with differential (CBC with diff)
o Low platelets may hinder coagulation
x Coagulation studies (prothrombin time with INR), liver enzymes (AST, ALT), albumin, BUN and
creatinine
x Guiac testing of stool (evaluates for blood in stool which is not readily visible.)
at what levels of hemoglobin should you transfuse?
if hemogloblin is below 7 g/dl (low risk patients) or below 9 g/dl (high risk
patients – elderly, heart disease),
what values may be inaccurate with UGI bleed?
hemoglobin
what are the initial interventions for UGI bleed?
- 2 large bore IVES
- consider central line placement (in IVC)
- consider intubation (supplemental O2 before)
what are indications for a central line?
inadequate
peripheral venous access or infusion of materials that would be damaging to peripheral veins,
i.e. chemotherapy.
what fluids should be infused with blood is not available?
-crystalloid fluids
what fluids should be infused if blood products will be administered?
-NS
when do you give Fresh Frozen Plasma or Prothrombin Complex Concentrate
for international Normalized Ratio - INR >1.6
what should platelets be kept at if actively bleeding?
> 50,000 if actively bleeding
how many units of PRBC should you cross and match?
2-4 units
EGD (esophagogastroduodenscopy)
A camera is attached to a flexible hose that is
inserted into the patient’s oropharynx and advanced to identify the source of the bleed. Once
identified, other tools can also be utilized within the mechanism to inject medications or perform
procedures.
what is combined with sclerotherapy to decrease risk of rebleeding?
endoscopy with band ligation
what can be used as an alternative to sclerotherapy?
thrombotic agent
what are some interventional radiology procedures for UGI bleed?
x Trans arterial embolization OR
x Transjugular intrahepatic portosystemic shunt (TIPS) procedure to reduce portal systemic
pressure shunting blood away from varices.
what is a TIPs procedure?
A tract is created between the portal vein and
hepatic vein and a stent is placed to maintain patency. The shunting the venous return of the
gut away from the liver, reduces the pressure in the portal vein.
when is surgical intervention reserved for?
cases where endoscopic and TIPS is not indicated
or is not available.
what are surgical interventions for UGI bleeds?
x Surgical resection and vessel ligation: depending on the site of the bleed, part of the stomach or
duodenum may be removed. In the case of variceal hemorrhage, part of the vessel may be
removed (resected) and stapled but has a high incidence of rebleeding.
x Splenorenal shunt: the splenic vein is detached from the portal vein and reattached to the left
renal vein reducing the pressure in the esophageal varices, controls bleeding and clotting.
Pharmacological Agents: for UGI bleed
Proton Pump Inhibitors - Omeprazole or esomeprazole 40 mg IV BID for peptic ulcer disease during
initial endoscopy
meds For known or suspected esophagogastric variceal bleeding and/or cirrhosis:
x prophylactic antibiotics: 1g ceftriaxone or a fluoroquinolone 400mg BID
x octreotide (somatostatin) 50mcg IV bolus and then drip at 50mcg/hr
x may help shunt blood away from varices
x reduces secretions and loss of body fluid
what are indications for packed red blood cells?
Acute hemorrhage with hemodynamic instability (hemorrhagic shock)
Acute anemia with inadequate oxygen delivery
Treatment of choice if hemoglobin concentration < 7 g/dL (or < 9 g/dL in high
risk patients)
what are indications for plasma
Portion of blood that remains after the cellular elements (red and white blood
cells) and platelets have been removed
what are indications for fresh frozen plasma
Used to correct coagulation deficiency; factor V and factor VII are available for
up to 24 hours after thawing
what are indications for cryoprecipitate?
Collected by thawing FFP at 4 o C and the collecting the white precipitate;
Contains von Willebrand factor, factor VIII, factor XIII and fibrinogen.
what are indications for immunoglobulin
Purified immunoglobulin fraction of plasma pooled from several thousand
donors.
Used to treat some autoimmune and immunodeficiency states
what are indications for platelets?
Used to stop active bleeding or prevent spontaneous bleeding in cases of
thrombocytopenia.
WHOLE BLOOD
IS NOT USED FOR TRANSFUSIONS EXCEPT IN RARE AND DIRE SITUATIONS.
Treatment of choice for anemia, even in the face of trauma is PRBC and crystalloid fluids.
where should your TART and tender point eval be focuesd?
T1-L2 region (T5-9 is specific to upper
GI)
Parasympathetics for the upper GI system
are linked to the vagus nerve (OA and AA joints)
Chapman points for Stomach acidity:
Left 5th ICS
Chapman point for Stomach peristalsis:
Left 6th ICS
Respiratory-Circulatory OS model UGI bleed
Volume resuscitation using crystalloids; evaluate for transfusion needs
Once the patient is stable, consider rib-raising or other gentle
maneuvers
Address C3-5, phrenic nerve to diaphragm fascia to improve excursion
and thus pressure gradients to the thoracic cage and associated lymph
movement.
Indirect MFR to thoracolumbar diaphragm to address
metabolic energy OS model UGI bleed
Endoscopy or Surgery to address source of bleeding.
Treat with PPI to facilitate healing of intestinal lining
Eliminate NSAIDS
Address nutritional needs (alcoholics commonly have deficits of B12
and Folate, in particular)
biomechanical OS model UGI bleed
Address somatic dysfunctions, OA/AA, Thoracic spine; in the case of
upper GI bleed, T5-9 for upper intestine
neurologic OS model UGI bleed
Identify and treat viscerosomatic findings, Chapman reflex points and
celiac ganglion
behavioral OS model UGI bleed
Assess patient for excessive alcohol use and counsel for cessation
