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LMCC Part II > UGIB > Flashcards

UGIB Flashcards

1
Q

define UGIB

A

bleeding proximal to the ligament of Tretiz (fourth part of the duodenum)

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2
Q

what causes UGIB

A

duodenal ulcer 25%

gastric ulcer 20%

acute gastric erosions 20%

esophageal varices 20%–> 30% mortality

mallory weiss tear 10%

Boerhaave’s syndrome (spontaneous rupture of the lower esophagus… high mortality)

aortoenteric fistula (high mortality)

gastric carcinoma

AV malformations

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3
Q

what factors are important to ask on history for UGIB

A

quantify bleeding

constipation or diarrhea?

associated symptoms–pain, N/V, fevers, chills, dizziness, urgency, weight loss, fevers, night sweats?

symptoms of anemia–weakness, headache, lightheadedness, palpitations

diet

recent trauma, colonoscopy, gastroscopy

PMHx

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4
Q

how do you quantify the bleeding in UGIB

A

how much blood? frequency?

tarry stools/melena? bright red blood/hematochezia? mixed into or surrounding stool?

hematemesis? bright red or coffee ground?

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5
Q

diet should you ask about with UGIB

A

pepto bismol
iron supplements
beets
licorice

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6
Q

what should you ask on PMHx for UGIB

A

previous bleeds and their cause

PUD

H pylori infection

unstable angina

dysphagia, heartburn

AAA

abdominal aortic graft

stomach ca

clotting disorder

alcohol use

liver disease

previous varices

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7
Q

what meds to ask about for UGIB

A

NSAIDs
warfarin
ASA
clopidogrel

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8
Q

what should you pay attention to on physical exam for UGIB

A 
vitals and assessment of volume status
general appearance
pallor
postural vitals
LOC

cool extremities for peripheral shut down

cardiac and resp failure

DRE with occult blood testing if unsure

abdominal exam

signs of chronic liver disease

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9
Q

what are signs of chronic liver disease

A 
palmar erythema
spider nevi
caput medusae
gynaecomastic
clubbing
testicular atrophy
jaundice
ascites
leukonychia
peripheral edema
bruising
Dupuytrens contracture
fetor hepaticus
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10
Q

what investigations should you order for UGIB

A

CBC, lytes
type and screen–>order up 2-6 units
BUN, Cr
PT/PTT, INR

  • remember that HgB remains normal until 6 hours later following fluid shifts causing hemodilution
  • expect elevated BUN due to digestion of blood with urea absorption
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11
Q

what imaging should you do for UGIB

A

abdo xray
cxr
diagnostic endoscopy
angiography vs rbc scan to detect active bleeding

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12
Q

when should you use an NG tube in UGIB

A

if diagnosis is uncertain

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13
Q

how should you manage an UGIB

A

2 large bore IVs in moderate to severe cases

IV NS or ringers and/or tranfuse to stabilize hemodynamics

  • -IV pumps if necessary to force in large amounts of crystalloid
  • -non crossmatched O- blood

therapeutic endoscopy for all significant bleeds
–80% of bleeds stop spontaneously

ranitidine

IV octreotide for bleeding varices

IV pantoloc infusion

treat H pylori infection

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14
Q

what should you use for bleeding varices

A

IV octreotide

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15
Q

what meds are used in the management of UGIB

A

octreotide
pantoloc infusion
ranitidine

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16
Q

how do you treat H pylori infection

A

“PAC”

PPI + amoxicillen + clarithromycin

omeprazole 20 mg PO BID
amoxicillen 1 g PO BID
clarithromycin 500 mg PO BID
all for 7 days followed by repeat testing to confirm success

17
Q

what are clinical predictors of poor UGIB outcome/high risk of re-bleed

A

hematemesis (especially bright red vs coffee ground)

hypotension

age above 60

comorbidity

bleed recurring during hospitalization

more than 10 units of blood transfused

18
Q

what are endoscopic predictors of poor UGIB outcome/high risk of re-bleed

A

high gastric ulcer

large or posterior duodenal ulcer

presence of adherent clot or oozing blood

non bleeding visible vessel

actively bleeding vessel

19
Q

when should you suspect perforated duodenal ulcer

A

intense pain radiating to the back

elevated amylase

possibly shock

suspicious if xrays reveal pneumoperitoneum

20
Q

management of perforated duodenal ulcer

A

requires emergent surgery as has high mortality

21
Q

what are two possible complications of UGIB

A

perforated duodenal ulcer

hepatic encephalopathy

22
Q

why might you develop hepatic encephalopathy in UGIB

A

precipitated in cirrhotics by increased urea from digested blood

endoscopic treatment of varices–sclerotherapy and banding

23
Q

how do you prevent recurrent peptic ulceration

A

dx H pylori by biopsy during endoscopy or urea breath test

of H pylori +, requires eradication therapy

discontinue NSAIDs until bleeding stops
–if NSAIDs must be restarted, then offer cytoprotection with misoprostol (200mg PO BID)

omeprazole 20 mg PO BID may be offered in short term (2 weeks) to enable complete healing

LMCC Part II (52 decks)

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