Clincial: GI Bleeding Flashcards
Hematemesis vs hematochezia vs melena
Hematemesis = vomiting blood “coffee-ground”
- the GI bleeding is proximal to the ligament of tretiz (ascending duodenum)
Hematochezia = blood in the stool that is bright red/maroon
- **lower GI bleed
- bright red = rectum/anus direct bleed
- maroon = ascending colon usually
Melena = blood in the stool that is dark brown/black
- **upper GI bleed
- ***watch out for patients taking peptobismal since this can mimic this (difference is stool sample will show normal heme if stool change is due to pepto bismuth; high heme if due to bleed)
When to use NG lavage?
Indications:
- Need to drain or feed stomach and bypass mouth
- pain and positive heme stools WITHOUT hematemesis present
Contraindications:
- facial fractures
- hematemesis is present
- esophageal varices may be present or are known to be present (if patient has cirrhosis be careful)
Can normal liver enzymes mean serious disease?
YES
Often in chronic liver cirrhosis, the liver enzymes will be normal since they just producing enzymes
Predictors for upper GI bleed
Positive (implies upper GI)
- vomits blood
- melenic stools are present
- positive NG lavage aspirate (if doing NG lavage)
- BUN:creatinine ratio = >30
Negative (implies lower GI bleed)
- blood clots in stool or bright red stool
- any of the positive not present
severe bleeding positive predictors = all positive above + tachycardia and hemoglobin <8
What is the modified blatchFord score?
Criteria that depicts how risky a GI bleed is and how likely urgent intervention is required
- *needs all of the following to not need urgent intervention
BUN:creatinine <18.2
Hemoglobin >11
Systolic blood pressure > 108
Heart rate <100
No melena
No syncope
no history of CHF or liver cirrhosis/disease
what is the Safety net in GI bleeding
IV fluids
O2 cannula
Give octerotide medications for esophageal and upper GI bleeding (give via IV)
Give PPI to reduce acid and prevent further damage and risk of rebleeding (give via IV bolus)
Give a prokinetic (metroclopermide) or NG tube to flush stomach out
Give antibiotics (ceftriaxone) for prophylaxis
**vasopressin is last resort all of the above doesn’t work and they are still bleeding **
** if actively bleeding needs 2 16 gauge IVs in them**
start with bleeding by giving saline and fluids, however if they have CHF or varices history DONT give this (fluid overload)
Type and screen (TandS) vs type and cross (TandC)
Type and screen = screen for blood type,Rh and specific auto antibodies that could cross react with blood used before blood transfusions
- *doesnt prepare the blood for transfusion though**
- this is that is normally ordered, unless you know you are gonna have to transfuse blood
Type and cross = same as above but it also prepares donor blood to be used immediately
- DOES prepare blood for transfusion and requires that blood to be used or thrown away**
- more sensitive and gives blood right away but can risk throwing blood away
*if actively bleeding and hypotensive, just type and cross and give blood anyways
When do we give blood
1) When actively bleeding and there is belief that it is severe
And hasent responded to IV and octerotide)
2) If stable appearing, but hemoglobin is <7, can give blood (if has heart disease <9)
if they have an active variceal bleed, should keep hemoglobin under 10 until repair. Going above it will overload the system and worsen the bleed
What is the mass transfusion protocol?
Given in extreme bleeding issues (40% or greater in total blood volume)
Give blood in 4:1/ 4:2ratio of
(packed red blood cells: FPP)
Minnesota or blakemore tubes
Are used when endoscopy and GI surgery is not available for GI bleeding
Provides two inflation tubes (1 gastric and 1 esophageal) which can block bleeding in the GI tract temporally
- gastric tube = 500 mL air
- esophageal tube = 30-40mmHg pressure
What is the most common cause of significant upper GI bleeding?
Peptic ulcer disease (PUD)
- increased risk is found in (H. Pylori infections, NSAIDs, tobacco use)
the most common upper GI bleed with insignificant bleeding is a Mallory Weiss tear, however this is often not severe/significant bleeding*
Is an upper or lower GI bleed more common when blood is in the stool?
Upper GI bleed
With bleeding, what is the #1 way to determine if someone is unstable or not?
how FAST they have lost blood
- overall blood volume loss and hemoglobin numbers can signal unstable, however if its taken them multiple weeks to lose this blood vs hours, then hours would be more unstable for sure
What does maroon vs black stools tell you?
Maroon-red = lower GI bleed (usually ascending colon)
Black = upper GI bleed
What is the most common cause of Hematochezia?
Diverticulosis of the colon
especially between 40-60 yrs of age
