Upper GI Bleeding Flashcards
3 causes of GI bleeds
Ulcer (most common)
Mallory-Weiss tear (from dry heaving)
Varices (biggest GI bleed)
Causes of stress ulcers
Trauma
Sepsis
Burns (called a Cushing’s ulcer)
CNS disease (called a Cushing’s ulcer)
*Gastric anoxia (hypotension) = biggest issue
How is gastric anoxia caused?
The minute your body gets low enough blood volume, it starts turning off non-essential body systems
1st = the gut. Acid is then left in gut and tries to digest. Starts digesting gastric mucosa
What is a Mallory-Weiss tear?
A tear in the mucosal layer at the junction of the esophagus and stomach
Causes of Mallory-Weiss tears
Forceful retching - pregnancy (Most common cause)
Drugs - NSAIDs, alcohol
What causes esophageal varices?
Develop as a result of portal hypertension (*due to right sided heart failure and liver failure, usually from chronic alcoholism)
Pressure requirements of esophageal varices
- Normal pressure 2-6 mmHg
- As pressure increases (>10 mmHg), vessels dilate, enlarge, and varices develop
- Bleeding occurs when portal pressure > 12 mmHg and can be profuse
How will blood loss from a GI bleed show up?
As:
- Hematemesis
- Melena
- Hematochezia
- or in Occult bedside test
What is hematemesis?
Vomiting blood
(Common with GI bleed)
Color = bright red
What is melena?
Dark tarry stools, look like coffee grounds
Can occur with upper GI bleed because blood has been digested
What is hematochezia?
Bright red blood in stool
Lower GI blood, caused by hemorrhoids
What is occult?
Blood in stool
Detected by guiac test (bedside stool test)
Usually occurs with lower I bleed b/c it’s chronic
Clinical manifestations of hypovolemia from GI bleeds
Decreased blood pressure
Increased heart rate
Decreased UOP
Decreased gastric motility (gut is being turned off)
Cool, clammy skin
Decreased LOC
What caused the pain/discomfort from a GI bleed?
Comes from cramping and body trying to digest all of the blood
Usually only occurs with a stomach or lower bleed
When should we intervene when a pt has a GI bleed?
When they start showing S/S of decreased cardiac output
When a pt is showing symptoms of decreased cardiac output due to a GI bleed, what is the first choice to help?
*fluid, which will buy time to find best drug to help
What is the first sign of the body trying to compensate when a patient with a GI bleed has decreased cardiac output?
Vasoconstriction from release of epi and norepi
What happens if the body can’t compensate for decreased cardiac output?
The pt will go into multi-system failure:
Decreased perfusion to brain, kidneys, and lungs
How do you determine if a patient has gone into multi-system failure yet?
By looking at their lab studies. If creatinine is effected, they are in organ failure. If not, then you aren’t yet
What lab values will you see with a pt with a GI bleed?
Decreased H&H (24-48 hr after bleeding starts)
Increased WBCs (due to hemoconcentration)
Electrolytes and BUN reflect dehydration
Gastric pH will be low (acidic)
Liver function will be altered (but depends why pt is in this state) and ammonia if liver disease suspected
*What is the gold standard for diagnostic tests for upper GI bleeds?
*Endoscopy
Nurses role in endoscopy
Done at pt’s bedside so nurse cleans room and follows instructions
You are the one to leave the room and get blood if needed
Endoscopic nurse verifies blood with you
Functions of an endoscopy
Can view to try to determine site of bleeding
Take samples
Inject drugs to stop bleeding
All diagnostic tests for upper GI bleed
Endoscopy
Tests for H/ pylori
Barium studies
Why are tests done for h. Pylori? and how are they done?
Large amounts cause more gastric acid production
A wire is sent down endoscope that snips tissue samples to be cultured for overgrowth
Priority treatments for GI bleed
Fluid/blood resuscitation
- *1st: Packed Red blood cells for HCT <25%
- NS
Nasogastric tube
- gastric lavage with room temp NS
What is hetastarch (Hespan)?
An option to give pt with hypovolemia
A temporary expansion of volume by means of starch
Concentrated sugar (starch)
Expands in vascular space to provide artificial volume for 1-2 hrs
When bag runs out, starch dissolves and you’re back to low volume (any inflation of BP is temporary)
First choice of fluids for a pt with hypovolemia?
Isotonic fluids:
*Normal saline (b/c same tonicity as blood)
LR ok, but not the best
*do not want to give hyper or hypo tonic solutions b/c they will shift fluid and we don’t have fluid to shift
What is the first choice for an actual solution for a pt with hypovolemia?
250 mL bag of packed red blood cells (not #1 choice b/c takes time to prepare them in lab - have to cross type and match)
Why aren’t platelets a best choice for a patient with hypovolemia?
Need to be bagged or pulled from other bags and pooled into one single bag. Takes 4-6 hours so not fast enough
What isn’t plasma a best choice to give to a patient with hypovolemia?
Must be thawed and spun, so takes 4-6 hours and isn’t fast enough
Prophylaxis for stress ulcers
Famotidine
Pepcid
Omeprazole
Pharmacologic therapy for upper GI bleeds
Antacids
Histamine blockers (H2 blockers)
Mucosal barrier enhancers
Proton pump inhibitors (PPIs)
Antibiotics
How do antacids help with GI bleed?
Provides mucosal coating for relief
Examples of histamine blockers that help with GI bleeds
Famotidine
Cimetidine
Example of mucosal barrier enhancer
How does it work?
Sucralfate (brand name = carafate)
Liquid that looks like mylanta
Coats esophagus to let areas of irritant ion heal
(30-45 mL increments down tube or swallowed)
Example of proton pump inhibitor
Omeprazole
How does Omeprazole work?
Blocks hydrogen and gastric acid production
(Capsule and can’t go down tube)
Drug of choice for H. Pylori overgrowth?
Flagyl
3 treatment strategies that can be used with endoscopy
Sclerotherapy
Electrocautery
Band ligation
When do the treatment strategies during endoscopy need to be done?
All wishing 6-12 hours of onset
What drugs are used for sclerotherapy?
Injection of drug into irritated area
Drug = optriatide or synthetic vasopressor
What is electrocautery?
Burning of the affected area to stop bleeding
What is band ligation?
Best treatment for varices, band is tied around affected area and eventually it dies and falls off
When is surgical treatment of GI bleeds considered?
For massive bleeds that are uncontrollable with medical therapy or if immediately live-threatening.
(Must stabilize the pt first)
Usually considered in pts who require >8 units of blood in 24 hours
And on pts who have tried the other treatments with no success
Types of surgical treatment
Gastric resection
Vagotomy
Pyloroplasty
What is a gastric resection?
Taking out a majority or the pt’s gut
Will have malabsorption, malnutrition, trouble eating, trouble swallowing
What is a vagotomy?
Clipping of the vagus nerve
Limits the ability of the vagus nerve to stimulate hydrochloric acid
Could affect the way a pt looks b/c the vagus nerve is in the jaw
What is a pyloroplasty?
Probably the best option
Irritated area is removed and replaced with healthy tissue
Drug options specific to esophageal varices
Octreotide (somatostatin)
Vasopressin (synthetic ADH)
Actions of octreotide (somatostatin)
Selective vasoconstrictor
Slows or stops bleeding with fewer risks that vasopressin
Nursing considerations for octreotide
Infusion for up to 5 days
Monitor for alterations in blood sugar
Actions of vasopressin
Vasoconstrictor
Lowers portal pressure (by shunting blood to other places, creates new path for fluids that body will remember though, so could be dangerous)
Decreases flow to collateral circulation
Vasopressin considerations / Side effects
Chest pain
ECG changes
Increased BP (may give NTG)
Renal failure
Hyponatremia
N/V
Decreased LOC
Edema
Ascites worsens
Name of balloon tamponade for esophageal and gastric bleeding
*Blakemore
How is a blakemore balloon tamponade inserted?
Insertion is just like normal bedside NG tube placement
*need xray to confirm placement and “ok to use”
BEFORE inflating balloons
Inflate gastric balloon first to anchor, then esophageal balloon
Nursing considerations for balloon therapy
X-ray prior to inflating balloon
Elevate HOB
Label all lumens (to know which inflate/deflate balloons)
Scissors at BS
Gentle traction
Gauze under nose
Frequent mouth care
NGT irrigation (if clot or clogged area)
Wrist restraints
Monitor pressures (will have order for)
Deflate at set intervals per policy
Complications of balloon therapy
*Rupture of gastric balloon and migration upward
*Esophageal rupture = sudden and severe pain
Gastric or esophageal ulcerations
Ulceration of nose and/or mouth
Procedure for shunting for varicies is called
TIPs procedure
(Transjugular intrahepatic portosystemic shunt)
Risk for TIPs procedure
High risk for encephalopathy
Who would not be eligible for a TIPs procedure?
A patient who is waiting for a transplant
Once the TIPS procedure or any other type of shunt is done, they are no longer eligible for a liver transplant)
