1. HYHO: UGIB

Question 1

Presentation of a patient with UGI bleed

Answer 1

1. Hematemesis = vomit blood
2. Coffee ground emesis
3. Melena (dark stools)
4. Hematochezia (red/maroon blood in stool)
5. Anemia
6. Hypovolemic shock

Question 2

How does a patient with hypovolemic shock present?

Why?

Answer 2

Cold, clammy, vasoconstriction due to low BV detected by baroreceptor reflex => increase HR, sympathetic stimulation and vasoconstriction of non-essential organs

Question 3

What symptoms can a person with hypovolemic shock face?

Answer 3

1. Orthostatic hypotension

2. Tachycardia

Question 4

What is the landmark that divides a UGIB from a LGIB?

Answer 4

Ligament of Trietz (the suspensory l. of the duodenum)

Question 5

What are specific causes of UGIB?

Answer 5

1. Peptic ulcer
2. Esophageal ulcer
3. Mallory-Weiss tear
4. Variceal hemorrhage or portal HTN gastropathy
5. Cancer

Question 6

What specific symptoms indicate: peptic ulcer, esophageal ulcer and Mallory Weiss tear?

Answer 6

1. Peptic ulcer: abdominal pain
2. Esophageal ulcer: odonyophagia, dysphagia, GE reflux
3. Mallory-Weiss tear: emesis, retching or coughing BEFORE hematemesis

Question 7

What aspects of history are important to check in a patient with UGIB?

Answer 7

1. History of GI or nose bleeds
2. PUD
3. Esophogeal or gastric variceal bleeding in pts with cirrhosis or chronic alcoholics.

Question 8

What meds can form peptic ulcers => UGIB?

Answer 8

1. Aspirin
2. NSAIDS (ibuprofin, naproxen sodium)

Question 9

What meds can promote bleeding?

Answer 9

1. Antiplatelet drugs (clopidrogel)
2. Anticoagulants (warfarin)

Question 10

What patients can alter the presentation in one with a UGIB?

Answer 10

1. Bismuth (pepto-bismol)
2. Iron

Question 11

PE for UGIB (4)

Answer 11

1. Vital signs
2. Confusion (=> lack of O2 to brain)
3. Peripheral vasoconstriction (=> cool extremities and cyanosis)
4. Signs of liver disease (jaundice, ascites, and caput medusa)

Question 12

Labs for UGIB (4)

Answer 12

1. CBC w/ diff
2. Cogulation studies (PT with INR)
3. Liver enzymes (AST/ALT)
4. Albumin, BUN and creatinine
5. Guiac stool testing

Question 13

If HB is below _________/__________ low-risk patients/high-risk patients => transfuse

Answer 13

• Low-risk patient => below 7 g/dl
• High-risk patient => below 9g/dl

Question 14

Steps involved in resuscitation of a patient with severe UGIB.

Answer 14

1. *** Focus on circulating volume
2. Airway and circulation
3. Obtain urgent consulation and treat

Question 15

What should be the INITIAL resuscitation focus in a patient with a UGIB?

Answer 15

• Correct circulating volume (hemodynamic stability)

Question 16

If a patient with a UGIB is hemodynamically unstable, what do we do?

Answer 16

1. Give 2 large bore IV access (16-18 gauge) in different limbs
2. Central line ONLY IF: cannot access peripheral venous circulation or infusion would damage peripheral veins
3. Replace blood
4. If no blood => cystalloid fluids. If blood => NS

Question 17

How should airway and circulation be controlled in UGIB? (3)

Answer 17

1. Supplimental O2 and monitor on pulse ox
2. Intubate to perform endoscopy
3. Balloon tamponade for bleeding

Question 18

If INR > 1.6, give _____

Answer 18

1. Fresh frozen plasma
2. Prothrombin complex concentrate

Question 19

If actively bleeding, keep platelets ______

Answer 19

> 50,000

Question 20

What should be done in a patient with UGIB to make sure if a transfusion is needed, we do not have to waste time and check blood types against donated blood?

Answer 20

Cross and match 2-4 units of blood-PRBC.

Question 21

What procedure can be done to ID source of bleeding?

Answer 21

• EDG (esophagogastroduodenoscopy) = looks at the eso, stomach, and first part of duodenum.

Question 22

How can we visualize and treat esophageal varices?

Answer 22

Endoscopy with band ligation

Question 23

When endoscopy with band ligation is combined with _________ => lower risk of rebleeding and mortality

Answer 23

Endoscopy + Sclerotherapy (IV injection that irritates the vein => causes it to close)

Question 24

Interventational radiology procedures for UGIB?

Answer 24

1. Trans-arterial embolization
2. TIPS procedure (tranjugular intrahepatic portosystemic shunt) => reduce portal systemic pressure by shunting blood AWAY from varices

Question 25

When is **surgery indicated** for UGIB and what types are done?

Answer 25

* Perform surgery when cannot perform **TIPS or endoscopy,** or not available. * Surgeries * **1. Surgical resection and vessel ligation** * **2. Splenorenal shunt**

Question 26

Meds for PUD

Answer 26

**PPI** (_Omeprazole_ or _esomeprazole_ 40mg IV BID)

Question 27

Meds for **esophogastric variceal bleeding** and/or **cirrhosis**.

Answer 27

1. **Prophylactic ABX:** 1g Ceftriaxone or 400mg BID of fluoroquinolone. 2. **50mcg IV bolus** and then trip at **50mcg/hr** of **Octetride (Somatostatin)** to shunt blood away from varices.

Question 28

* **DO NOT USE** _________ for transfusion, except in RARE and DIRE situations. * Treatment of choice for anemia, when if trauma: \_\_\_\_\_

Answer 28

* **Whole blood** * **PRBC + crystalloid fluid**

Question 29

OSE for GI system

Answer 29

1. TART and TP for **T1-L2 (T5 - 9 = \> UGI)** 2. **Parasympathetics** for UGI (vagus nerve = OA and AA joints) 3. **Chapman points for stomach acidity:** Left 5th ICS 4. **Chapman points for stomach peristalsis:** Left 6th ICS

Question 30

5 Factor Model for UGIB: Respiratory and Circulation (4)

Answer 30

* 1. Volume resuscitation w crystalloids and see if transfusion is needed. * 2. Once stable =\> rib raising * 3. Improve excursion of diaphragm by fucking with phrenic nerve (C3-5) * 4. Indirect MFR to thoracolumbar diaphragm

Question 31

5 Factor Model for UGIB: **Metabolic - NRG (4)**

Answer 31

1. Endoscopy/surgery to fix bleeding 2. Take PPI and DQ NSAIDS 3. Nutritional needs

Question 32

5 Factor Model for UGIB: **Biomechanical** and **behavioral**

Answer 32

1. **Biomechanical**: Fix SD: OA/AA and thoracic spine (T5-9) 2. **Behavioral**: stop excess alcohol and smoking.

Question 33

5 Factor Model for UGIB: Neurologic

Answer 33

1. Viscerosomatic findings 2. Chapmans points 3. **Celiac ganglion**

Question 34

When should OMT be done for a **UGIB**?

Answer 34

* **_After_** pt is stabilized and ID treatment of bleeding

Question 35

What 4 things should you remember for a **UGIB**?

Answer 35

1. **Recognize, resuscitate and intubate early** 2. **Consult GI, radiology and surgery** to dx and tx 3. **Give ABX** to patient

Question 36

Pt presents with **hematemesis** and **melena**. What is the first thing we do to determine course of action.

Answer 36

1. **Determine if the pt is hemodynamically stable or unstable** 1. **_Stable_**: upper endoscopy within 24 hours 2. **_Unstable_**: resuscitate, prep for emergency upper endoscopy and consult surgery and or interventional radiology if upper endoscopy cannot be performed.