Case-GIB

Question 1

What is a med class that predisposes pts to ulcers/UGIB

Answer 1

NSAIDS

Question 2

What BUN:Cr is indicative of a GIB

Answer 2

> 30:1

occurs because blood is absorbed as it passes through the small bowel and patients may have decreased renal perfusion. The higher the ratio, the more likely the bleeding is from an UGI source

Question 3

What would the etiology be if the Cr was >1 (if BUN >30)?

Answer 3

Renal

Question 4

You have a pt whose BUN:Cr is 45:1? What is the etiology?

Answer 4

GIB

Question 5

Normal AST range?

Answer 5

0-35IU

Question 6

Normal ALT range?

Answer 6

0-35IU

Question 7

Normal ALP range?

Answer 7

30-120IU

Question 8

Normal total protein?

Answer 8

6-8g/dL

Question 9

Normal total bili?

Answer 9

0-1mg/dL

Question 10

Normal albumin?

Answer 10

3.5-6mg/dL

Question 11

Normal Ca2+

Answer 11

8.5-10

Question 12

When do you check for corrected Ca2+?

Answer 12

If albumin <3.5mg/dL

Question 13

5 steps for initial GIB management in the ER

Answer 13

1. 2 large bore IVs 
(make pt NPO)
2. Type & Cross
3. 500- 1000cc Fluids 
(while waiting for blood)
4. Blood Transfusion 
(1unit PRBC)
5. find the bleed (call GI for EGD)
***stop the damn NSAIDS

Question 14

What Hgb do we transfuse at w/o sx?

What Hgb do we transfuse at if pts have sx or cardiac dz?

Answer 14

7 or less

8

Question 15

Ideal Time frame for endoscopy

Answer 15

< 12hrs

Question 16

Classification for Grading GIBs?

Answer 16

Forest classification

Question 17

Name the 6 Forest grades (worst to less bad)

Answer 17

1. Active spurting vessel
2. Oozing (active) vessel
3. Visible vessel, not bleeding (high risk for bleed)
4. Adherent Clot
5. Flat-pigmented spot
6. Ulcer, clean w/o blood
   (risk for rebleed)

Question 18

Tx options for GIB during EGD?

What can we add to the 2 Tx options?

Answer 18

**Clips
**Thermal coagulation (heat)
can add on Epinephrine (constriction of vessel)- NO FINGERS, NOSE, TOES, PENIS

Question 19

You can D/C a GIB if 3 things are present…

Answer 19

No comorbids
Hgb NL
Stable VS

Question 20

Every GIB should receive this med class (&dose)!

Answer 20

PPI
(pantoprazole/ esomeprazole)

80mg

Question 21

T/F: PPI for GIB can be given PO (acutely)?

Answer 21

False! IV only

Question 22

What are the positives of giving a PPI for a GIB (4)?

Answer 22

• Suppress gastric acid (increase pH of stomach)
(Up to 36hrs)
• Promote faster healing of ulcer
• Control PUD sx
• Stabilize blood clots /promotes hemostasis
(via higher pH)

Question 23

T/F: H2 blockers/combo PPI & H2 blockers work just as well as a PPI alone (IV)

Answer 23

False. not as good

Question 24

How long to continue PPI for GIB? can you do PO after bleed stopped 72hrs?

Answer 24

4-12 weeks

yes

Question 25

Education of GIB prevention (3): | Which is an independent risk factor for PUD?

Answer 25

1. Stop smoking 2. Stop drinking >1drink/d 3. Stop NSAID use (4x increase of PUD, as well as more refractory ulcers and increased rate of complications like bleeding) - Always ask about OTC drugs!!!!! Smoking is an individual risk factor for GIB

Question 26

DDx for PUD?

Answer 26

``` Esophagitis (reflux esophagitis) Mallory Weiss Tear Esophageal Varices from portal HTN Upper GI tumor Angiodyspasia (Varicose Vein in GIT) ```

Question 27

Etiology in this case? How did our pt get a GIB? What else can cause the etiology?

Answer 27

PUD NSAIDS, ETOH, Smoking -H. pylori

Question 28

T/F: Bx for H.pylori is accurate if taken during an EGD?

Answer 28

True, but if bleeding, a (-) result cant r/o H. Pylori | Use urea breath or stool Ag to confirm (-) test

Question 29

What drug can be used to reduce splanchnic blood flow & inhibit gastric acid secretion & useful if EGD not avail for 72hrs?

Answer 29

Octreotide (SST)

Question 30

When should a pt go back on ASA after a GIB? What circumstances?

Answer 30

After bleeding stopped. | IF Hx of CVA, CAD

Question 31

What Physical Exam is SUPER IMPORTANT for suspected GIB?

Answer 31

DRE

Question 32

What part of Hx is super important for GIB?

Answer 32

Medications | =NSAIDS

Question 33

What part of Objective is SUPER important for GIB?

Answer 33

Labs

Question 34

How do we calculate who is low risk and can be managed as outpatient or discharged early after EGD for GIB?

Answer 34

-Glasgow Blatchford Score (GBS) or Rockall score calculate risk

Question 35

Using the risk scores, we can calc who is low risk and can be dc’d early/ managed output. Which risk score can be calculated before EGD? After EGD?

Answer 35

``` Glasgow-Blatchford Scale-Calculated before EGD results Uses: BUN Hgb SBP pulse presence of melena syncope hepatic Dz, and/or HF. ``` ``` Rockall-After EGD results Based on: age presence of shock comorbidity Dx EGD results. ```

Question 36

T/F:All patients with PUD should undergo testing for H. pylori.

Answer 36

True

Question 37

When can you switch from IV to PO PPI in GIB from PUD?

Answer 37

72hrs after endoscopy (stop bleed)

Question 38

Some Signs of GIB (5)

Answer 38

``` Slightly pale. Tachycardic. Mild generalized abd tender (+)hemoccult stool dizzy when standing ```

Question 39

If a pt needs ASA therapy after a GIB, what Rx should they use as maintenance therapy to reduce risk of ulcer complications/ reoccurrence?

Answer 39

PPI Omeprazole 20mg QD