10/6- GI Hemorrhage Flashcards Preview

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Flashcards in 10/6- GI Hemorrhage Deck (48)
1

What is "upper" GI bleeding?

- What percentage of GI bleeding cases does it account for?

Bleeding proximal to the ligament of Treitz

- 50% of admissions for GI bleeding

2

Etiology of upper GI bleeding?

- Peptic ulcer – 38%

- Varices – 16%

- Esophagitis – 13%

- Malignancy – 7%

- AVM – 6%

- Mallory-Weiss Tear – 4%

- Erosions – 4%

- Dieulafoy’s – 2%

- Unknown – 8%

3

What is this? 

Esophageal cancer

4

What is this?

Mallory-Weiss tear (GE junction)

5

What is this?

NG tube trauma

6

What causes the majority of peptic ulcer disease?

1. H. pylori infection

2. NSAID use

7

What is the pathophysiology behind bleeding in cirrhosis?

Portal hypertension develops from:

- increased resistance to flow due to the architectural distortion of the liver along with

- intrahepatic vasoconstriction from decreased nitric oxide

Results in porto-systemic collaterals

- Hepatic venous pressure gradient (HVPG)

  • Normal 3-5mmHg
  • Esophageal varices develop above 10-12mmHG

- Varices present in 50% of cirrhotics, presence correlates with severity of liver disease

- Varices appear at 8% per year, small become large at 8% per year

- Variceal hemorrhage 5-15% per year, risk associated with large varices, decompensated cirrhosis, and red wale signs

- Variceal bleeding = 20% mortality at 6 weeks

- Gastric varices in 5-33% of patients with portal hypertension, 25% bleeding risk in 2 years

8

What is portal hypertensive gastropathy?

Chronic slow blood loss/anemia

9

What is gastric antral vascular ectasia?

Anemia; does not respond to TIPS/b-blockers

10

What is this? 

Snake skin appearance of portal hypertensive gastropathy

11

What is this?

"Watermelon stomach" of gastric antral vascular ectasia

12

What should be covered in the history for evaluating upper GI bleeding?

- Prior bleeding episodes, from what source?

- Alcohol use

- History of liver disease

- GERD

- Weight loss, N/V, family history malignancy

13

What medications may contribute to upper GI bleeding?

- Ulcers can develop within a week of starting aspirin/NSAIDs

Combination antiplatelets/anticoagulants

  • Aspirin and clopidogrel
  • Aspirin and warfarin
  • Aspirin, clopidogrel, and warfarin

- Dabigatran, rivaroxaban

14

What should the physical exam cover in the evaluation of upper GI bleeding?

- Vital signs

  • Tachycardia
  • Orthostasis – at least 15% blood loss
  • Supine hypotension – 40% blood loss

- Signs of chronic liver disease

- NG tube: possibly wash and see if blood comes back

- Stool examination

15

What are the benefits of Fecal Occult Blood testing?

- What is it not diagnostic for?

- Has been shown to reduce mortality from colorectal cancer

- Cancer detection test – recommended as an alternative to patients who decline a cancer prevention test (colonoscopy)

- No role in evaluation of a patient presenting with GI bleeding

16

What are the important lab results in evaluating upper GI bleeding?

- H/H - BUN (prerenal rise in BUN)

- PT/INR

- Evidence of chronic liver disease and/or portal hypertension (bilirubin, albumin, INR, platelets)

17

What four questions should you ask yourself in the clinical assessment of someone with upper GI bleeding?

Is this a GI bleed?

- Combo of history, lab values, and vital signs which come together to make a believable story

Is this an active bleed?

- Ongoing hematemesis or melena, continued hemodynamic instability, failure to respond to transfusion (taking into account resuscitation)

Where is the source?

Is the patient stable?

18

What signs point to the location of GI bleeding?

- Hematemesis/coffee ground emesis: upper GI source

- Melena: upper GI through proximal colon

- Hematochezia: brisk upper GI through rectal bleeding

- Negative NG lavage does NOT exclude an upper GI source

19

What are prognostic scores of upper GI bleeding: Rockall?

0-3

- Based on age, shock, comorbidity, diagnosis, major SRH...

20

What are prognostic scores of upper GI bleeding: Blatchford?

Based on:

- Blood urea

- Hemoglobin

- Systolic BP

- Other markers

21

What are prognostic scores of upper GI bleeding: AIMS 65 Score?

1 point (5 max) for:

- Albumin under 3.0 mg/dL

- INR > 1.5

- Altered mental status

- SBP under 90 mmHg

- Age > 65 yo

22

What is treatment for upper GI bleeding?

Hospitalization

- Admission

- ICU vs. floor

- Suspected variceal bleeding Intubation

- Encephalopathic cirrhotic

- Prophylactic for EGD?

Resuscitation!

Transfusion

Medical therapy

Endoscopy

23

Adequate vs. inadequate resuscitation?

Left: inadequate

Right: adequate

24

Transfusion strategies for upper GI bleed?

Restrictive strategy (7 g/dL to goal 7-9) was better than liberal (9 g/dL to goal 9-11) strategies

Hazard ratios with restrictive strategy:

- Death within 45 days 0.55 (95% CI 0.33 – 0.92)

- Further bleeding 0.62 (0.43 – 0.91)

- Adverse events 0.73 (0.56 – 0.95)

25

What is medical therapy prior to endoscopy in a non-cirrhotic patient with an upper GI bleed?

Proton pump inhibitor drip (omeprazole, esomeprazole, pantoprazole)

Reduce acid

- Allow normal platelet aggregation for hemostasis

- Allow ulcer/esophagitis to heal

26

What is medical therapy prior to endoscopy in a cirrhotic patient with an upper GI bleed?

Octreotide (somatostatin analog)

- Reduce portal pressures

Antibiotics (ceftriaxone or ciprofloxacin)

- Prophylaxis against spontaneous bacterial peritonitis (SBP) and bacteremia PPI – cirrhotics can also have ulcers

27

What is the goal of antisecretory therapy?

How is it accomplished?

Goal is pH > 6 to allow normal platelet aggregation

- IV PPI bolus/infusion is the most effective

28

What is the most important medical treatment in upper GI bleeds?

Antibiotics in the cirrhotic patient

- This actually improves mortality

29

What is the significance of timing with an endoscopy?

- Generally low quality evidence

- Earlier endoscopy = more likely to find high risk stigmata -> more likely to receive endoscopic therapy

- Patients with UGIB should undergo endoscopy within 24 hours

- Patients with high risk features may have improved clinical outcomes with endoscopy within 12 hours

30

What is the purpose of performing an endoscopy?

- Diagnosis

- Risk stratification

- Endoscopic therapy

31

What are conditions requiring post-endoscopy meds?

- Peptic ulcer diseas

- Varices

32

What is seen here?

Clean base

33

What is seen here? 

Flat red spots; low risk

34

What is seen here?

Adherent plaque; need to remove and find ulcer

35

What is seen here? 

Visceral area; protuberant instead of flat

- Much higher risk

36

What is seen here? 

Left: adherent clot

Right: treated?

37

What is seen here? 

Actively bleeding/oozing ulcer

38

What is seen here?

Active arterial spurting; very high risk

39

T/F: IV PPI after endoscopic treatment of bleeding ulcers improves need for surgery and 30 day mortality

False; does neither

40

What are some other considerations after treatment of bleeding ulcers?

Ensure follow-up of H. pylori testing (serology or biopsy) with treatment and confirmation of eradication

- Amox/clari/metro/PPI

- Bismuth/tetracycline/metro/PPI

Restart aspirin prior to discharge in patients who have a good indication

41

What is seen here?

Whale sign; visible vessel

42

What is seen here? 

We treat peptic ulcers with banding (?)

43

What is after treatment for varices?

- Continue prophylactic antibiotics to complete a maximum of 7 days

- Continue octreotide to complete 3-5 days

- PPI for prophylaxis against banding ulcer bleeding

- Repeat endoscopy for ablation of varices

44

What should be done when endoscopy fails?

Refractory ulcer bleeding

- High risk ulcers

Refractory variceal bleeding

- Gastric varices when cyanoacrylate not available

- Esophageal varices that fail endoscopic therapy Interventional radiology and surgery

45

What are the main causes of lower GI bleeding?

- Diverticulosis (30%)

- Hemorrhoids (14%)

- Ischemic (12%)

- IBD (9%)

- Post-polypectomy (8%)

- Colon cancer/polyps (6%)

- Rectal ulcer (6%)

- Vascular ectasia (3%)

- Radiation colitis/proctitis (3%)

- Other (6%)

46

What should be considered in the history when evaluating a lower GI bleed?

- Abdominal pain, diarrhea, weight loss

- History of IBD (Crohn’s, ulcerative colitis)

- History of GI malignancy

- Recent colonoscopy (with polypectomy)

- Radiation to prostate

- Abdominal aortic aneurysm

Consider upper GI source

- 15% of cases of hematochezia from upper GI source

- Significant hematochezia with orthostasis or hypotension requires EGD

- Consider NG lavage

Can have melena from small bowel or right colon (may also need colonoscopy, especially if EGD negative)

47

What is management for lower GI bleeding?

Resuscitation, transfusion

Colonoscopy

- Therapeutic

- Can find non-bleeding stigmata

- Visualization may be limited by blood

Tagged RBC scan (0.04 mL/min)

- Safe, only diagnostic

- Requires active bleeding

Angiography (0.5 mL/min)

- Therapeutic

- Requires active bleeding

- Risks of contrast dye

Surgery

- Need to localize and identify source prior to surgery

- Malignancy

- Recurrent diverticular bleeding

48

Endoscopy treatment for varices and ulcers?

Varices: banding Ulcers:

- Metal clip

- Epenephrine