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Clin Therapeutics II (Spring 2018) > Exam 1: GI emergencies (bleeds, APAP OD) > Flashcards

Exam 1: GI emergencies (bleeds, APAP OD) Flashcards

1
Q

How do people present with UGIB?

A

Hematemesis / Melina / hematochezia

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2
Q

Epidemiology of GI bleeds (HINT: incidence, which end more common, which sex more common)

A

100/100,000

UGIB 4x common

M>F

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3
Q

Upper GI Bleed is proximal to which ligament?

A

Ligament of Treitz in duodenum

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4
Q

MC cause of Upper GI Bleed?

A

Peptic ulcer

Another high RF is Mallory Weiss tear d/t vomiting

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5
Q

Meds which can cause Upper GI Bleed? (hint: 3)

A
  1. ASA
  2. NSAIDs
  3. Prednisone

Anticoagulants too

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6
Q

2 types of Upper GI Bleed?

A

Non-variceal

Variceal

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7
Q

Variceal Upper GI Bleed bleed due to pressure increase where?

A

Increased pressure in portal vein from liver disease

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8
Q

“Better after I eat” means Upper GI Bleed is most likely where?

A

Duodenum. Would be worse with stomach bleed.

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9
Q

What scoring system do you use for UGIB risk stratification. What does it predict. What factors contribute to score (HINT 3)

A

Rockall scoring. Validated predictor of mortality with UGIB

AGE: <60, 60-79, >80

SHOCK: (SBP>100, HR <100), (SBP>100, tachy), (hypotension SBP <100)

Comorbidity: no major, cardiac failure/CAD, renal/liver failure and malignancy

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10
Q

What increases risk of UGIB (HINT: comorbidities, age, H&H, presenting sx)

A
  • CV compromise
  • Age > 65
  • consisting cardio/resp dz
  • Hgb < 10 (HCT<30)
  • hematemesis and Melena
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11
Q

What in a patient’s hx would make you concerned for UGIB? (HINT: comorbidities, social activities, meds, prev surg)

A

-Prev bleeding—bleeds likely to rebelled
-EtOH/Liver dz
-Steroids—PUD/esophagitis
-Liver dz—Esophageal/gastric varicies
-anticoagulant/NSAIDs
-severe vomiting—Mallory Weiss Tear
Aortic surgery-aortoenteric fistula

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12
Q

What does emesis look like in Upper GI Bleed?

A

Coffee ground

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13
Q

Stool in Upper GI Bleed?

A

Large black tarry stool (aka melena)

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14
Q

Hematemesis, Melena, Hematochezia in which GI bleed?

A

Upper GI Bleed

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15
Q

BUN/Cr 36:1 without renal insufficiency highly suggests what?

A

Upper GI Bleed

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16
Q

What BUN/Cr is dehydration?

A

20:1

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17
Q

What BUN/Cr suggest upper GI bleed?

A

36:1

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18
Q

How to fluid resuscitate Upper GI Bleed?

A

2 large bore IVs

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19
Q

Keep elderly HCT above what in Upper GI Bleed?

A

> 30%

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20
Q

When to give FFP in Upper GI Bleed?

A

If >10 units blood required AND fibrinogen <1, or INR 1.5x normal

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21
Q

When to give PLT in Upper GI Bleed?

A

PLT <50k with active blood

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22
Q

How to treat Peptic Ulcer in Upper GI Bleed?

A

High dose IV PPI!

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23
Q

When to contact GI with an Upper GI Bleed?

A

ASAP!

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24
Q

How to dx Upper GI Bleed? What else can you also do with this diagnostic

A

Endoscopy

Can also tx with mechanical clips +/- epi, cautery, or fibrin/thrombin. +/- epi

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25
Q

Emergent management of UGIB (tx in ER)

A

1 stabilize the pt: airway, circulation, ID source

Fluids: 2 large bore IV
Type+screen. Keep hct over 30 in elderly
FFP if>10 units of blood, fibrinogen <1 or INR 1.5X Normal
Platelets if <50K and bleeding
Early endoscope
High dose IV PPI for UGIB

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26
Q

What if can’t find Upper GI Bleed with endoscopy?

A

Angiography
Useful if bleeding persists and endoscopy fails to ID bleeding site

Angiography with transcatherter arterial embolization for all UGIB with known source of arterial and negative endoscopy

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27
Q

Tx plan for Upper GI Bleed?

A

Resuscitation and early endoscopy->banding +/- sclerotherapy

if still bleeding in 5-7 days repeat banding +/- sclerotherapy -> vasoconstrictor +/- tamponade

if fail endoscopy x2 and med therapy->consider TIPPS

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28
Q

How many times to try endoscopy with banding in Upper GI Bleed? When?

A

Twice if still bleeding in 5-7 days

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29
Q

When to consider TIPSS in Upper GI Bleed?

A

Fail endoscopy x2 and med therapy

-refractory bleeding/ascites, Bud-Chiari clots

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30
Q

What does PT need after TIPSS?

A

New liver

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31
Q

Goal pressure for Portal Vein in Upper GI Bleed?

A

<12mmHg. Can’t bleed below that pressure.

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32
Q

General categories of tax for varicies

A 
Endoscopic: banding or sclerotx
Medical: Octreotide
Tamponade: Sengstaken-blakemore tube/balloon
Surgery: Shunts
TIPSS
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33
Q

Complications of TIPS surgery

A
  • Restenosis, occlusion, thromboembolism
  • Hepatic encephalopathy d/t ammonia buildup
  • Hemorrhage, hemobilia, cholangitis
  • Stent migration
  • Heart failure, liver failure
  • infection
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34
Q

Prevention of variceal bleeds

A

Octreotide, Beta blockers: propranolol BID (hold if low bp)

Banding ppx

Long acting nitrates

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35
Q

H Pylori therapy? (hint: 3)

A
  1. PO PPI
  2. Clarithromycin,
  3. Amoxicillin OR Metronidazole for 7-14 days
36
Q

Treatment for varicies

A 
Endoscopic banding/sclerotherspy
Octreotide (SST analog)
Tamponade with balloon
Shunts
TIPS
37
Q

What 3 therapies are equivalent for variceal treatment

A

Somatostatin = sclerotherapy = tamponade

38
Q

Which med to give for vasoconstriction in Upper GI Bleed? What med to go along with it?

A

Vasopressin. NTG for heart and spleen to loosen constriction.

39
Q

If using pressure techniques for variceal bleeds, what is the longest the balloon should be inflated for?

A

Inflated less than 24 hours

40
Q

What is used for primary/secondary treatment of variceal bleeds?

A

Beta-blockers (Propanolol 40-80mg BID)

Primary: seen in cirrhosis —> ?ppx banding
Secondary: once bleed settles—> Bblocker

Long acting nitrates

Goal: keep PV pressure < 12
Soft foods

41
Q

Where is lower GI Bleed located?

A

Distal to Ligament of Treitz

42
Q

Which is more common- Upper GI bleed or Lower GI bleed?

A

Upper GI bleed by 4x

43
Q

Major cause of Lower GI Bleed?

A

Diverticulosis

44
Q

Bright colored blood in stool means what?

A

Bleed is close to rectum. “Hematochezia”.

45
Q

Other causes of LGIB

A 
Angangioectasias
Hemorrhoids
Colitis: (IBD, infections, ischemic)
Neoplasm
Post-polypectomy
Dieulafoy’s lesion
46
Q

What defines severe LGIB

HR and SBP which make Lower GI Bleed “severe”?

A

HR>100
SBP<115

Continued bleeding w/in 24 hrs, decline in HCT and recurrent bleeding

47
Q

Abdomen feels like what in Lower GI Bleed?

A

LLQ discomfort, crampy

48
Q

Predictors for severe LGIB (HINT 7)

A
  • HR >100
  • SBP <115
  • Syncope
  • Nontender abdominal exam
  • Bleeding during first 4 hrs of evaluation
  • ASA use
  • > 2 active comorbid conditions
  • 0 Factors – 6% risk
  • 1-3 Factors 40% risk
  • > 3 is 80% risk
49
Q

What percent of Lower GI Bleed resolve spontaneously?

A

80%

50
Q

What percent of Lower GI Bleed which resolve spontaneously rebleed?

A

30%

51
Q

Dx for stable Lower GI Bleed? And how soon should pt have this.

A

Colonoscopy within 6-12 hrs or presentation (CAUTION IN UNSTABLE PT)

Requires Rapid purge prep with 5-6L go lytely administered at rate of 1 L q 30-45 minutes
Colonoscopy within 1 hr of clear stools

52
Q

What test if active bleed with hematochezia in Lower GI Bleed?

A

NG lavage

53
Q

NG lavage positive when in Lower GI Bleed?

A

Brown

54
Q

Dx for unstable Lower GI Bleed?

A

Angiography +/- Tagged RBC scan

55
Q

Dx for Lower GI Bleed if unstable, active, and no angiography available?

A

CT Angio

56
Q

Tx for stable active Lower GI Bleed?

A

Urgent Colonoscopy

57
Q

Tx for unstable active Lower GI Bleed?

A

Angiography +/- Tagged RBC scan.

Surgery if lifethreatening.

58
Q

Why Angiography over Tagged RBC scan

A

Tagged RBC scan lacks tx capability

Angiography great for bleeds that cant be stabilized or prep for colonoscopy.
Thx capability: embolization with microcoils, polyvinyl alcohol and gelfoam

59
Q

Complications of angiography

A 
Bowel infarction
Renal failure
Hematoma
Thrombosis
Dissection
60
Q

4 therapeutic actions of APAP

What doesn’t APAP DO

A

Analgesia (same efficacy as salicylate)
Inhibits brain prostaglandin syntherase
Blocks pain impulses peripherally
Antipyretic

NOT anti inflammatory

61
Q

Max dose of Acetaminophen?

A

4g

62
Q

Potentionally lethal dose of Acetaminophen?

A

15g

63
Q

Acetaminophen causes what to deplete?

A

Glutathione->increased NAPQI->hepatic necrosis

64
Q

Half-life of Acetaminophen if liver healthy?

A

2h

65
Q

Half-life of Acetaminophen if liver dysfunctional?

A

Up to 17h

66
Q

Adult liver damage from APAP at which dose?

A

> 150mg/kg or

>7.5g in 24h

67
Q

Children liver damage from APAP at which dose?

A

> 200mg/kg

68
Q

How many phases of Acetaminophen Toxicity?

A

4

69
Q

Overall complications of APAP toxicity

A 
Jaundice d/t inc bill
Renal failure
HyperLactatemia
Metabolic acidosis
Hypophosphatemia, hypo or hyper glycemia
*cardiac arrhythmia
Pancreatitis, GIB, cerebral edema
70
Q

Phase 1 of Acetaminophen Toxicity? Duration and what?

A

30min-4hr. Anorexia, nausea, vomiting, pallor, diaphoresis

71
Q

Phase 2 of Acetaminophen Toxicity? Duration and what?

A

24-48h. RUQ pain d/t hepatic dmg, increased LFT, inc PTT, decreased renal function

72
Q

Phase 3 of Acetaminophen Toxicity? Duration and what?

A

3-5 days. Hepatic necrosis, jaundice, renal failure, coag defect, hepatic encephalopathy

73
Q

Phase 4 of Acetaminophen Toxicity? Duration and what?

A

4days - 2 weeks. Complete resolution or death.

74
Q

When to do GI Decontamination in Acetaminophen Toxicity?

A

Within 1-2 hours ingestion.

75
Q

How to do GI Decontamination in Acetaminophen Toxicity?

A

Ipecac + gastric lavage. Activated charcoal 50-100g. Cathartic to speed transit time.

76
Q

When to take APAP level in Acetaminophen Toxicity?

A

4 hours post-ingestion

77
Q

What is toxic value in Acetaminophen Toxicity?

A

150mg/dl at 4h from lab

78
Q

What do you need to know in order to plot APAP level?

A

When APAP was taken

79
Q

What tx for Acetaminophen Toxicity is a substitute for glutathianone?

A

NAC

80
Q

Loading dose of NAC for Acetaminophen Toxicity?

A

140mg/kg x1

81
Q

Maintenance dose of NAC for Acetaminophen Toxicity?

A

70 mg/kg q4h x17 doses

Give 4hr after loading.

82
Q

What if puke during NAC maintenance dose in Acetaminophen Toxicity?

A

Repeat dose and give Reglan

83
Q

Is hemodialysis an effective tx for APAP Tox?

A

NO! not proven effective in reducing or prevent infections liver damage in OD

84
Q

What LFTs are elevated with APAP tox? When will they be elevated ?

A

AST/ALT think hepatocellular injury
Repeat q24h
Elevation at 24-36

85
Q

Which liver enzyme is specific for liver damage?

A

ALT

86
Q

What PTT level is associated with poor <8% survival in APAP toxicity

A

PTT > 180s

Clin Therapeutics II (Spring 2018) (11 decks)

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