Upper GIB and Jaundice

Question 1

Hematemesis, melena, hematochezia, occult, symptoms of blood loss or anemia:

Answer 1

1. Vomiting of red blood or “coffee grounds” material (upper GI source, or small bowel)
2. Black, tarry, foul smelling stool (blood present in GI tract for at least 12-14 hrs; maybe small bowel source)
3. Passage of bright red or maroon blood from rectum (think lower GI source, unless patients with hemodynamic instability)
4. Loss of overt bleeding, but iron deficiency or positive fecal occult blood test
5. Lightheadedness, syncope, angina, dyspnea

Question 2

Most common cause of upper GI bleeding:

Answer 2

1. Ulcers
2. Varices
3. Gastroduodenal erosions

Question 3

Melena with ____ blood, and hematochezia with _____ blood

Answer 3

50-100 cc’s; 1000 cc’s

Question 4

Most common cause of UGI bleed:

Answer 4

peptic ulcer (think NSAIDs or H pylori infection)

Question 5

Mallory-Weiss tears can present with

Answer 5

vomiting, retching, or coughing preceding hematemesis, ESPECIALLY in alcoholics (think lower esophageal tear)

Question 6

Suspect esophageal varices in

Answer 6

those with cirrhosis; it’s the POOREST outcome among all UGI bleeding cases

Question 7

Hemorrhagic and erosive gastropathy/gastritis associated with

Answer 7

NSAID use, alcohol intake, and stress (trauma, surgery, burns)

Question 8

Treating peptic ulcer bleed:

Answer 8

PPI, get rid of H pylori;

also avoid NSAIDs, but if they are clinically indicated use PPI’s also

Question 9

Endoscopic therapies and stigmata of recent hemorrhage:

Answer 9

Thermal, injection (Epi), mechanical (clips/bands);
Clean based ulcer and flat spot/pigmentation with low risk of rebleed;
adherent clot, visible vessel (greater risk of rebleed and needs upper endoscopic therapy), active bleeding (high risk of rebleed)

Question 10

Acid suppression and PUD bleeding:

Answer 10

1. need platelet aggregation and fibrin formation with pH over 6.8 (can use PPIs)
2. Keep pepsin inactive with pH greater than 4

Question 11

Most common causes of SI sources of bleeding:

Answer 11

1. Vascular ectasias, tumors, and NSAID-induced erosions and ulcers in adults
2. Meckel’s diverticulum in children (significant lower GIB)

Question 12

For colonic sources of bleeding:

Answer 12

Hemorrhoids, then anal fissures;
think diverticula, vascular ectasias, neoplasms, and colitis for LGIB;
in children, think IBD and juvenile polyps

Question 13

Diverticular bleed is

Answer 13

abrupt in onset, painless, and massive LGIB; usually stops spontaneously bleeding

Question 14

With hemodynamic instability, do

Answer 14

upper endoscopy

Question 15

Jaundice, or ____, is a

Answer 15

yellowish discoloration of tissue resulting from bilirubin deposition; think liver dysfunction or maybe hemolytic disorder

Question 16

What gives color to urine and feces? Bilirubin in urine is ____ and suggests

Answer 16

Urobilins and stercobilins;
conjugated;
liver dysfunction or glomerular disease

Question 17

Urobilinogen is

Answer 17

water soluble; lost to the urine and contributes to color

Question 18

Conjugated hyperbilirubinemia suggests;

unconjugated suggests

Answer 18

genetic defects in excretion, or hepatobiliary disease (extra- or intrahepatic cholestasis);
overproduction, impaired conjugation, and impaired hepatic uptake

Question 19

Pre-hepatic, hepatic, and post-hepatic etiologies of jaundice:

Answer 19

Unconjugated: Increased production (hemolysis, blood transfusion, ineffective erythropoiesis), decreased hepatocellular uptake (rifampin), decreased conjugation (Gilbert’s, Crigler-Najjar, physiologic newborn jaundice) vs. Dubin-Johnson or Rotor’s (conjugated);

Viral hepatitis, alcoholic hepatitis, ischemic hepatitis, toxins (acetaminophen, wild mushrooms), autoimmune hepatitis, biliary cirrhosis, cholestatic conditions; high
AST/ALT suggestive of hepatic disease

Choledocholithiasis, diseases of bile ducts, extrinsic compression

Question 20

Jaundice due to liver disease has history of; jaundice due to bile duct obstruction has

Answer 20

anorexia, malaise, myalgias (viral prodrome); also see ascites on PE and also predominant elevation of serum aminotransferases with prolonged PT time that doesn’t correct with vit K admin;

abdo pain, fever, rigors, history of previous biliary surgery; also has high fever, abdo tenderness, palpable abdo mass;
and predominant elevation of serum bilirubin and alk phos, with PT time that is normal or normalizes with vit K admin