4 - Upper And Lower GI

Question 1

UGI bleeding above:

Answer 1

Ligament of Treitz

Question 2

MCC of UGI

Answer 2

Peptic ulcer dz

Question 3

Increased risk for PUD

Answer 3

Smoking
ASA
NSAIDs
H. pylori

Question 4

Cause of esophageal varices?

Answer 4

Portal HTN

EtOH abuse

Liver dz

Question 5

Mallory-Weiss Syndrome

Answer 5

Longitudinal mucosa tear at the GEJ (weak point)

Due to repeated vomiting followed by bright red hematemesis

Associated with drunks, DKA, chemo

Also, excessive coughing or seizures

Question 6

What can masquerade as UGI?

Answer 6

ENT bleeding

Question 7

Unusual but important cause of UGI

Answer 7

Aortoenteric fistula 2/2 preexisting aortic graft

Leads to exsanguination via hematemesis and/or hematochezia

Question 8

Classically, what suggests a UGI source?

Answer 8

Coffee-ground emesis and hematemesis

Question 9

Hematemesis following retching suggests:

Answer 9

Mallory-Weiss tear

Question 10

Bright red or maroon rectal bleeding unexpectedly originates from UGI sources how often?

Answer 10

Only about 14% of the time

What does this mean? If it’s bright red or maroon, it’s POSSIBLE that its UGI, but less likely

Question 11

Associated sxs with UGI bleed

Answer 11

HOTN
Tachycardia
Angina
Syncope
Weakness
Confusion

Question 12

What may occur even in the face of profound hypovolemia?

Answer 12

Paradoxical bradycardia

Question 13

Which findings lead you toward liver dz?

Answer 13

Spider angiomas

Palmar erythema

Jaundice

Gynecomastia

Question 14

Most important test during UGI?

Answer 14

Type and cross (in case you need it)

Question 15

Why is BUN high in acute UGI bleed?

Answer 15

Digestion and absorption of Hgb

If lower, doesn’t really have time to break-down or absorb it so not as much elevation

Question 16

What is a single elevated lactate level a sentinel sign of?

Answer 16

Severe illness (in GI bleed pts)

Question 17

What study is CI’d in GI bleed?

Answer 17

Barium contrast

Question 18

In a patient without hx of hematemesis, a (+) NGT aspirate provides what?

Answer 18

Strong evidence for a UGI source of bleeding

Question 19

Does a negative nasogastric tube aspirate r/o UGI?

Answer 19

Nope

False negatives possible for a number of reasons

Question 20

Most reliable way to dx UGI bleeding in the ED?

Answer 20

Visual inspection

Question 21

Is NGT CI’d for pts with esophageal varices?

Answer 21

Nah.

Question 22

Predictors of worse outcomes for UGI

Answer 22

Older patients
Comorbidities
Red hematemesis
Hematochezia
Red blood on NG aspirate
Hemodynamic instability
Abnormal lab studies

Prior variceal banding, clamping or cauterization of an ulcer bed

Question 23

Initial management of UGI bleed

Answer 23

Stabilize!

Two large-bore IV’s

If unstable, a couple boluses of fluid

Draw blood for type and cross

Aggressively resuscitate PRIOR to intubation

Question 24

Blood transfusion guidelines for UGI bleed

Answer 24

If hemoglobin is 7 or less - give blood

If hemoglobin is 9 or less in elderly, give blood

Question 25

When to treat coagulopathy in UGI bleed?

Answer 25

If INR is high Or platelets less than 50K Or Severe bleeding

Question 26

Omeprazole guidance for UGI bleeding

Answer 26

80mg IV bolus

Question 27

Octreotide use for what UGI bleeding?

Answer 27

Varices

Question 28

ABX for UGI bleeding?

Answer 28

Cipro for Cirrhosis

Question 29

Blood transfusions can be life-saving, YET:

Answer 29

Liberally transfusing patients with a high H/H threshold can cause harm In other words, just because someone is bleeding doesn’t mean they need blood products

Question 30

An INR > or equal to ______ is a significant predictor of mortality (in a patient NOT on Warfarin)

Answer 30

1.5 Indicates significant clotting and/or bleeding problem

Question 31

TXA in UGI bleeding?

Answer 31

No benefit

Question 32

PPI’s in UGI bleeding?

Answer 32

Reduce the need for surgery, length of stay in hospital, and signs of bleeding Bc remember, most UGI bleeds are 2/2 PUD

Question 33

How does octreotide work?

Answer 33

Inhibits secretion of gastric acid Reduces blood flow to gastroduodenal mucosa, causes splanchnic vasoconstriction

Question 34

Diagnostic study of choice for UGI?

Answer 34

Endoscopy (EGD) Allows you to see the source (in most cases) AND administer hemostatic therapy Do it early (w/in 24hrs of presentation) If unstable, do it now

Question 35

Where does surgery fall that txt algorithm?

Answer 35

Last

Question 36

LGI bleeding

Answer 36

Occurs less often than UGI Less serious than UGI bleeding

Question 37

The MC source of all bleeding per rectum is:

Answer 37

UGI bleeding

Question 38

LGI bleeding more common in?

Answer 38

Females and elderly

Question 39

Percentage of LGI bleeding that resolved spontaneously?

Answer 39

80%

Question 40

Painless bleeding?

Answer 40

Consider diverticular bleeding 2/2 diverticulosis

Question 41

Features of diverticular bleeding

Answer 41

Usually left-sided Usually self-resolves Can be massive, but not common

Question 42

Mesenteric ischemia can lead to:

Answer 42

Bowel necrosis Causes include: thrombosis, embolism, etc

Question 43

Ischemic and mesenteric ischemia patients:

Answer 43

``` Over 60yrs Afib CHF MI Postprandial abd pain Unexplained weight loss ```

Question 44

Study of choice for ischemic and mesenteric ischemia?

Answer 44

Angiography CT is good, too

Question 45

Prognosis for mesenteric ischemia?

Answer 45

Terrible - 50% mortality even with aggressive treatment

Question 46

Causes of LGI bleeding

Answer 46

Slide 51

Question 47

The MC source of LGI bleeding?

Answer 47

Hemorrhoids

Question 48

Factors associated with shitty outcomes in LGI bleed

Answer 48

``` Hemodynamic instability Repeated hematochezia Gross blood on initial rectal exam Initial crit under 35% Syncope ``` NONTENDER ABD = PREDICTOR OF SEVERE BLEEDING ASA or NSAID USE

Question 49

What sxs may suggest malignancy?

Answer 49

Weight loss and changes in bowel habits

Question 50

Meds that can increase risk of LGI bleeding

Answer 50

Salicylates NSAIDs Coumadin

Question 51

Bedside test to check for internal hemorrhoids?

Answer 51

Anoscopy

Question 52

Bleeding from a source higher in the GI tract may elevate:

Answer 52

BUN

Question 53

Scintigraphy (nuke med)

Answer 53

More sensitive than angiography and can localize the site of bleeding at as low a rate as 0.1mL/min

Question 54

Is high res CTA a good test?

Answer 54

100% for detecting active or recent bleed

Question 55

Is diarrhea genetic?

Answer 55

Or does it just run in my jeans?