Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

MS2 GI > 10/6- GI Hemorrhage > Flashcards

10/6- GI Hemorrhage Flashcards

1
Q

What is “upper” GI bleeding?

  • What percentage of GI bleeding cases does it account for?
A

Bleeding proximal to the ligament of Treitz

  • 50% of admissions for GI bleeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Etiology of upper GI bleeding?

A
  • Peptic ulcer – 38%
  • Varices – 16%
  • Esophagitis – 13%
  • Malignancy – 7%
  • AVM – 6%
  • Mallory-Weiss Tear – 4%
  • Erosions – 4%
  • Dieulafoy’s – 2%
  • Unknown – 8%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is this?

A

Esophageal cancer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is this?

A

Mallory-Weiss tear (GE junction)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is this?

A

NG tube trauma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What causes the majority of peptic ulcer disease?

A
  1. H. pylori infection
  2. NSAID use
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the pathophysiology behind bleeding in cirrhosis?

A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is portal hypertensive gastropathy?

A

Chronic slow blood loss/anemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is gastric antral vascular ectasia?

A

Anemia; does not respond to TIPS/b-blockers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is this?

A

Snake skin appearance of portal hypertensive gastropathy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is this?

A

“Watermelon stomach” of gastric antral vascular ectasia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

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

A
  • Prior bleeding episodes, from what source?
  • Alcohol use
  • History of liver disease
  • GERD
  • Weight loss, N/V, family history malignancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What medications may contribute to upper GI bleeding?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

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

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the benefits of Fecal Occult Blood testing?

  • What is it not diagnostic for?
A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

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

A
  • H/H - BUN (prerenal rise in BUN)
  • PT/INR
  • Evidence of chronic liver disease and/or portal hypertension (bilirubin, albumin, INR, platelets)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

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

A

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?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What signs point to the location of GI bleeding?

A

- 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are prognostic scores of upper GI bleeding: Rockall?

A

0-3

  • Based on age, shock, comorbidity, diagnosis, major SRH…
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are prognostic scores of upper GI bleeding: Blatchford?

A

Based on:

  • Blood urea
  • Hemoglobin
  • Systolic BP
  • Other markers
21
Q

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

A

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
Q

What is treatment for upper GI bleeding?

A

Hospitalization

  • Admission
  • ICU vs. floor
  • Suspected variceal bleeding Intubation
  • Encephalopathic cirrhotic
  • Prophylactic for EGD?

Resuscitation!

Transfusion

Medical therapy

Endoscopy

23
Q

Adequate vs. inadequate resuscitation?

A

Left: inadequate

Right: adequate

24
Q

Transfusion strategies for upper GI bleed?

A

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
Q

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

A

Proton pump inhibitor drip (omeprazole, esomeprazole, pantoprazole)

Reduce acid

  • Allow normal platelet aggregation for hemostasis
  • Allow ulcer/esophagitis to heal
26
Q

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

A

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
Q

What is the goal of antisecretory therapy?

How is it accomplished?

A

Goal is pH > 6 to allow normal platelet aggregation

  • IV PPI bolus/infusion is the most effective
28
Q

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

A

Antibiotics in the cirrhotic patient

  • This actually improves mortality
29
Q

What is the significance of timing with an endoscopy?

A
  • 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
Q

What is the purpose of performing an endoscopy?

A
  • Diagnosis
  • Risk stratification
  • Endoscopic therapy
31
Q

What are conditions requiring post-endoscopy meds?

A
  • Peptic ulcer diseas
  • Varices
32
Q

What is seen here?

A

Clean base

33
Q

What is seen here?

A

Flat red spots; low risk

34
Q

What is seen here?

A

Adherent plaque; need to remove and find ulcer

35
Q

What is seen here?

A

Visceral area; protuberant instead of flat

  • Much higher risk
36
Q

What is seen here?

A

Left: adherent clot

Right: treated?

37
Q

What is seen here?

A

Actively bleeding/oozing ulcer

38
Q

What is seen here?

A

Active arterial spurting; very high risk

39
Q

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

A

False; does neither

40
Q

What are some other considerations after treatment of bleeding ulcers?

A

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
Q

What is seen here?

A

Whale sign; visible vessel

42
Q

What is seen here?

A

We treat peptic ulcers with banding (?)

43
Q

What is after treatment for varices?

A
  • 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
Q

What should be done when endoscopy fails?

A

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
Q

What are the main causes of lower GI bleeding?

A
  • 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
Q

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

A
  • 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
Q

What is management for lower GI bleeding?

A

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
Q

Endoscopy treatment for varices and ulcers?

A

Varices: banding Ulcers:

  • Metal clip
  • Epenephrine

MS2 GI (26 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions