Upper GI Bleeding Flashcards
What is upper GI bleeding?
Bleeding into the lumen of the proximal GI tract, proximal to the ligament of Treitz
What are the signs and symptoms of upper GI bleeding?
Hematemesis, melena, syncope, shock, fatigue, coffee-ground emesis, hematochezia, epigastric discomfort, epigastric tenderness, signs of hypovolemia, guaiac-positive stools
Why is it possible to have hematochezia with upper GI bleeding?
Blood is a cathartic and hematochezia usually indicates a vigorous rate of bleeding from the UGI source
Are stools melenic or melanotic?
Melenic
How much blood do you need to have melena?
> 50 cc
What are the risk factors for upper GI bleeding?
Alcohol, smoking, liver disease, burns, trauma, NSAIDs, vomiting, sepsis, steroids, previous UGI bleed, PUD, esophageal varices, portal hypertension, splenic vein thrombosis, AAA repair
What is the most common cause of significant upper GI bleeding?
PUD
What is the common differential diagnosis of upper GI bleeding?
- Acute gastritis
- DU
- Esophageal varices
- GU
- Esophageal
- Mallory-Weiss tear
What is the uncommon differential diagnosis of upper GI bleeding?
Gastric cancer, hemobilia, duodenal diverticula, gastric volvulus, Boerhaave’s syndrome, aortoenteric fistula, paraesophageal hiatal hernia, epistaxis, NGT irritation, Dieulafoy’s ulcer, angiodysplasia
Which diagnostic tests are useful for upper GI bleeding?
History, NGT aspirate, AXR, EGD
What is the diagnostic test of choice with upper GI bleeding?
EGD
What are the treatment options with the endoscope during an EGD?
Coagulation, injection of epinephrine, injection of sclerosing agents, variceal ligation
Which lab tests should be performed for upper GI bleeding?
BMP, bilirubin, LFTs, CBC, T&C, PT/PTT, amylase
Why is BUN elevated with upper GI bleeding?
Because of absorption of blood by the GI tract
What is the initial treatment for upper GI bleeding?
IVFs, Foley, NGT suction (determine rate), water lavage (remove clots), EGD
Why irrigate in an upper GI bleed?
To remove the blood clot so you can see the mucosa
What test may help identify the site of massive upper GI bleeding when EGD fails to diagnose cause and blood continues per NGT?
Selective mesenteric angiography
What are the indications for surgical intervention in upper GI bleeding?
Refractory or recurrent bleeding and site known; > 3u PRBCs to stabilize or > 6u PRBCs overall
What percentage of patients with upper GI bleeding require surgery?
10%
What percentage of patients with upper GI bleeding spontaneously stop bleeding?
80-85%
What is the mortality of acute upper GI bleeding?
Overall 10%
What are the risk factors for death following an upper GI bleed?
Age older than 60; shock; > 5u PRBC transfusion; concomitant health problems
What is PUD?
Peptic Ulcer Disease
What is the incidence of PUD in the US?
10%
What are the possible consequences of PUD?
Pain, hemorrhage, perforation, obstruction
What percentage of patients with PUD develops bleeding from the ulcer?
20%
Which bacteria are associated with PUD?
H. pylori
What is the treatment for H. pylori infection?
2-week regimen of either:
MOC: Metronidazole, Omeprazole, Clarithromycin
ACO: Ampicillin, Clarithromycin, Omeprazole
What is the name of the sign with RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?
Valentino’s sign
In which age group are duodenal ulcers most common?
40-65 years
What is the male:female ratio for duodenal ulcers?
3:1
What is the most common location for duodenal ulcers?
Most are within 2 cm of the pylorus in the duodenal bulb
What is the classic pain response to food intake with duodenal ulcers?
Food classically relieves duodenal ulcer pain
What is the cause of duodenal ulcers?
Increased production of gastric acid
What syndrome must you always think of with a duodenal ulcer?
Zollinger-Ellison syndrome
What are the risk factors for duodenal ulcers?
Male, smoking, NSAIDs, uremia, ZES, H. pylori, trauma, burns
What are the symptoms of duodenal ulcers?
Epigastric pain (burning, aching, usually several hours postprandial), bleeding, back pain, N/V, anorexia
What are the signs of duodenal ulcers?
Tenderness in the epigastric area, guaiac-positive stool, melena, hematochezia, hematemesis
What is the differential diagnosis of duodenal ulcers?
Acute abdomen, pancreatitis, cholecystitis, ZES, gastritis, MI, GU, reflux
How is the diagnosis of duodenal ulcer made?
H&P, EGD, UGI series
When is surgery indicated with a bleeding duodenal ulcer?
> 6 u PRBC overall; > 3 u PRBC to stabilize; significant rebleed
What EGD finding is associated with rebreeding of a duodenal ulcer?
Visible vessel in the ulcer crater, recent clot, active oozing
What is the medical treatment of duodenal ulcers?
PPIs or H2 receptor antagonists; treat H. pylori
When is surgery indicated for a duodenal ulcer?
I HOP: Intractability Hemorrhage Obstruction Perforation
How is a bleeding duodenal ulcer surgically corrected?
Opening of the duodenum through the pylorus and oversewing of the bleeding vessel
What artery is involved with bleeding duodenal ulcers?
Gastroduodenal artery
What are the common surgical options for duodenal perforation?
Graham patch;
Truncal vagotomy and pyloroplasty incorporating ulcer;
Graham patch and highly selective vagotomy;
Truncal vagotomy and antrectomy
What are the common surgical options for duodenal obstruction resulting from duodenal ulcer scarring?
Truncal vagotomy, antrectomy, and gastroduodenostomy;
Truncal vagotomy and drainage procedure (gastrojejunostomy)
What are the common surgical options for duodenal ulcer intractability?
PGV (highly selective vagotomy);
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII
Which ulcer operation has the highest ulcer recurrence rate and the lowest dumping syndrome rate?
PGV (proximal gastric vagotomy)
Which ulcer operation has the lowest ulcer recurrence rate and the highest dumping syndrome rate?
Vagotomy and antrectomy
Why must you perform a drainage procedure (e.g. pyloroplasty, antrectomy) after a truncal vagotomy?
Pylorus will not open after a truncal vagotomy