GI bleed

Question 1

case: lots of conditions, afib
epigastric abdominal pain
no black tarry stool
chronic or acute?

Answer 1

probably acute due to concerning vitals: hypotensive, tachy
if chronic would have compensated

INR: on warfarin
CBC: hgb

1st things to do:
fluid (L bolus)
type/screen for blood transfusion

Question 2

General approach to the GIB

Answer 2

Acute or Chronic?
Hemodynamic instability? ICU if not stable
Medications? OTC? (clopidogrel, warfarin, ASA, etc.) (new drugs: difficult to reverse)
Alcohol use?
Rectal exam? (bright red blood?) NG lavage? (blood? coffee grounds?: UGIB)

Question 3

can reverse warfarin with

Answer 3

FFP and vitamin K+ (long term)

Question 4

GIB tx

Answer 4

Fluids, +/- PRBC (blood transfusion), hold BP Rx, PPI, serial H+H, GI consult, No anticoagulants

Question 5

coffee ground emesis

Answer 5

slide 5, blood, acidity turns it black

Question 6

GIB background/terms

Answer 6

Is this acute or chronic?
Yes, HGB can be as low as 4 without any obvious hemodynamic instability
Hematemesis – bright red blood in vomit, or coffee ground type material
Melena – black, tar like stool

250,000 hospitalizations a year for acute upper GIB
Mortality 4-10%
Hematochezia – BRBPR (bright red blood per rectum) usually lower, but if
Massive upper GIB, can have this

Question 7

osteopathic

Answer 7

esopagus: T2-T8
upper GI: T5-T9, Greater Splanchnic Nerve Celiac Ganglion
middle GI: T10-T11, Lesser Splanchnic Nerve Superior Mesenteric Ganglion
lower GI: T12-L2, Least Splanchnic Verse Inferior Mesenteric Ganglion

Question 8

Acute Upper GI Bleed

Answer 8

Peptic Ulcer Disease: H. pylori

Portal Hypertension:
10-20% of cases
Can be massive due to esophageal or gastric varicose (problem if rupture, can bleed out)

Question 9

Hemodynamic Stabilization

Answer 9

BP Systolic less than 100: high risk
HR greater than 100 response to acute blood loss, first vital sign of change (UNLESS on B-blocker)
HCT takes 24-72 hours to equilibrate (trust your gut! pt may have normal levels but look very sick)

Question 10

initial steps

Answer 10

NG tube? Gastric Lavage? 
Rectal? 
Hemodynamic Stabilization 
Two large 18 gauge IV’s 
Type and Screen, CBC, INR/PT/PTT, CMP
0.9%NS until blood ready, if needed can use O – blood universal donor 
ICU? Central line?

Question 11

HGB goal: old guideline HGB: 10, too many risks from blood transfusions

new guidelines:

Answer 11

7 is threshold now, unless cardiac history then consider goal of greater than 9 (if having brisk bleed with complications, look at pt not numbers)
Platelets more than 50,000

Warfarin? INR high? Give FFP
Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC

Question 12

Uremia? (platelets there but don’t stick well together) ESRD Patient?

Answer 12

Consider DDAVP: promotes platelet adhesion

Question 13

Warfarin? INR high?

Answer 13

give FFB

with simple transfusion may dilute out clotting factors: Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC
vitamin K+ long term

Question 14

hx items

Answer 14

Aspirin?
NSAIDS?
NOAC? (?? anticoagulants)
Cirrhosis? (esophageal varices)

WHEN WAS THE LAST DOSE TAKEN?

clopidigrel, ASA take 10-14 days to get out of system (irreversibly bind)

Question 15

Role of Upper endoscopy

Answer 15

Stabilize patient first hemodynamically

if see bleeding vessel, clip it
Cautery, injection, endoclips (fall off on own)
Banding varices (left picture)
video: cauterize with epi

Question 16

pharm therapy

Answer 16

IV PPI: Bolus then drip for 72 hours
Consider PO PPI if low risk features (pantoprazole)

Octreotide

Question 17

Octreotide

Answer 17

Patient’s with esophageal or gastric varices, liver disease, portal HTN
Reduces splanchnic blood flow and portal blood pressures (IV not oral)

Question 18

PPI long term SEs

Answer 18

Potential decrease in non heme iron absorption with PPI has not been well studied

No good evidence to support PPI use affecting bone density or osteoporosis related fractures

~50 cases of hypomagnesemia associated with PPI use
(FDA recommended consider checking magnesium level before starting long term PPI therapy)

Question 19

acute lower GIB

Answer 19

Hematochezia
10% due to upper source
Definition: below ligament of Treitz

Question 20

diverticulosis

Answer 20

can erode into BV and cause bleeding

Acute, painless, large volume possible

Question 21

antioectasia

Answer 21

More common in CKD/ESRD patients

Question 22

other causes of acute lower GIB

Answer 22

Neoplasms
IBD
Anorectal disease (hemorrhoids, fissures)
Ischemic Colitis (older, nonocclusive ischemia, usually self limited)
Radiation induced proctitis

Question 23

L GIB

Answer 23

Exclude upper GIB: NGT, lavage
Rectal Exam
Colonoscopy or sigmoidoscopy: Prep with GoLYTELY 3.8L

Question 24

L GIB dx test: NM PRBC Scan

Answer 24

someone bleeding and don’t know where coming from
acts as tracer that will light up with active bleed

If positive, next step is angiography (interventional; can embolize)
Localization is poor, and only helpful if active bleed

Question 25

L GIB dx test: Push Enteroscopy or Capsule Study

Answer 25

successive pictures

sx??

Question 26

L GIB is typically

Answer 26

obscure

Question 27

know slide 20

Answer 27

Crohn’s vs UC

Question 28

Crohn’s

Answer 28

terminal ileum
"skip" lesions; irregular
transmural inflammation
crampy abd. pain
complic: fistulas, abscess, obstruction
XR: string sign w. barium
slight increase colon ca risk
sx: for stricture complications

Question 29

UC

Answer 29

rectum
proximally continuous
submucosal, mucosal inflammation
bloody diarrhea
complic: hemorrhage, toxic megacolon
XR: lead pipe colon on barium XR
*huge risk of colon Ca* (colonoscopy every few years)
sx is curative

Question 30

transfusions in acute upper GIB

Answer 30

Restrictive strategy group threshold of 7 g/dl
Goal 7-9
Liberal group threshold of 9 g/dl
Goal 9-11
Mortality at 45 days lower in restrictive strategy group 23/444 vs. 41/445

Subgroup with cirrhosis, risk of death was lower in restrictive strategy group 15/139 vs. 25/138

Question 31

Novel Anticoagulants in GIB

Answer 31

Pradaxa – dabigatran
Xarelto – rivaroxaban
Eliquis - apixaban

expensive, but do not have to check INR!
active w.in hrs (vs. coumadin)
advantage if bleeding, wear off quickly as well

Question 32

3 meds work as factor Xa inhibitor

??inhibit thrombin

Answer 32

diff than warfarin

Pradaxa – dabigatran blocks thrombin

Question 33

novel anticoagulants

Answer 33

risk of GIB is a little higher

hemorrhagic stroke risk is lower

Question 34

When to Resume Warfarin After GIB

Answer 34

7 days

Restarting warfarin after 7 days was NOT associated with increased risk of GIB, but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption.

Question 35

sometimes elderly pts on steroids/NSAIDS put on pentoprozol? to ??

Answer 35

prevent risk of bleed

sometimes don’t want to go on due to risk of C. diff

Question 36

recommendations for ASA

Answer 36

Use of low dose aspirin for cardiovascular prophylaxis associated with 2-4 fold increase in upper gastrointestinal events (81 mg just as effective as 325 mg, less GIB risk)
AHA recommends low dose aspirin in patient with 10 year cardiovascular risk > or = 10%
INR goal of 2-2.5 is recommended for:
Combination of aspirin and heparin/LMWH/warfarin or clopidogrel

Question 37

which ulcer more pain with eating??

what else?

Answer 37

Gastric ulcer – Greater with meals (pain)
Duodenal ulcer – Decreases with meals (pain)
Ischemic colitis – post-prandial abdominal pain, older patient, hematochezia

Question 38

medications

Answer 38

H2 blockers – famotidine, ranitidine – Block H2 receptors of parietal cells
PPI’s – omeprazole, pantoprazole (high risk C.diff) – Inhibit H+/K+ ATPase in parietal cells
? Low magnesium levels long term use, higher risk of C diff

Magnesium – Makes you go, take for constipation
Aluminium – minimum amount of feces, take for diarrhea
Osmotic laxatives – PEG, lactulose