Casefiles 6: upper GIB, SBS Flashcards
(48 cards)
Once the patient’s clinical problem of upper GI bleed is recognized, the appropriate priorities in this patient’s management are ?
(1) address the anemia and intravascular volume, (2) diagnosis, and (3) treatment
A critical step in the initial management of patients with acute upper GI bleeding is to determine ?
whether the bleeding is nonvariceal in origin or due to portal hypertension and bleeding from gastric and/or esophageal varices
Patients with suspected variceal bleeding should receive ?
octreotide and broad-spectrum antibiotics, empirically
For the patient with presumed nonvariceal bleeding, initiate treatment with ?
high-dose PPI, consisting of 80 mg omeprazole IV bolus followed by 8 mg/h IV drip for 72 hours.
may benefit from early (within 24 hours) upper GI endoscopy and possibly endoscopic intervention
think variceal bleed if ?
diagnosis of cirrhosis, hx of vatical bleed, ascites, thrombocytopenia, high INR, high bilirubin
think nonvariceal bleed if ?
NSAID or anticoagulant use
Dieulafoy’s erosion
rare GIB, occurs when erosion causes bleeding from aberrant submucosal artery located in the stomach
frequently significant and requires prompt diagnosis by endoscopy and endoscopic or operative control of bleeding
Isolated gastric varices most commonly develop as the result of ?
splenic vein thrombosis, which then produce “left-sided” or sinistral portal hypertension. With thrombosis of the splenic vein, blood return from the spleen can only return from the spleen through the short gastric veins, thus causing increase in pressure and size of the short gastric veins. This condition is correctable by splenectomy
Hemorrhagic shock severity: Class I
Well-compensated shock with generally normal vital signs and up to 15% or 750 mL blood loss in an average sized adult
Hemorrhagic shock severity: Class II
Slight tachycardia, normal systolic BP with elevated diastolic BP, associated with up to 30% or 750 to 1500 mL blood loss in an average adult
Hemorrhagic shock severity: Class III
Tachycardia to 120 associated with hypotension. Patient is generally anxious appearing and diaphoretic. The patient can have up to 40% blood volume loss or up to 2000 mL in an average size adult.
Hemorrhagic shock severity: Class IV
Tachycardia to 140 associated with severe hypotension. Patient is generally unresponsive with decreased mentation. The associated blood loss is greater than 40% of circulating volume or over 2000 mL.
The in-hospital mortality from acute upper GI bleedings is approximately ?, where most deaths are attributable to ?
10% to 15%
exacerbation of existing medical illnesses secondary to blood loss and shock
Glasgow Blatchford score (GBS)
a commonly used scoring system that takes into account patient’s pulse rate, SBP, Hgb, BUN, and medical comorbidities.
ranges from 0 to 23, and the score has been found to correlate with the patient’s need for early endoscopic interventions
Rockall score
combines clinical parameters and endoscopic findings, and the calculated scores have been shown to help predict individual patient’s rebleeding and mortality risks.
recent major change in the transfusion strategy for patients with acute upper GI hemorrhage, which now utilizes a restrictive transfusion approach when hemoglobin levels fall below ?
7 g/dL
-results in fewer transfusions, less bleeding, fewer adverse events, and had improved survival in comparison to patients in the liberal transfusion group
if upper GIB, get this in the first 24 hrs, as it is valuable for diagnosis, treatment, and risk stratification and prognostication
Upper GI endoscopy
can even employ hemostatic techniques: epinephrine injections, thermal application techniques, and clip applications
non-variceal bleeding causes
PUD, Gastritis/duodenitis, esophagitis, Mallory-Weiss tear, AVM, others (Dieulafoy’s and cancer)
What has emerged as an alternative to surgery for patients in whom endoscopic treatments have failed to control bleeding?
TAE: Transarterial Embolization
utilizes angiography to access the bleeding vessels and then control the bleeding either with the infusion of vasoconstrictive medication (vasopressin) or with mechanical occlusion by embolization
The indication for surgical control of nonvariceal bleeding is ?
to achieve hemostasis when endoscopic therapies fail
involves the creation of a gastrotomy or duodenotomy to access the bleeding area directly, followed by placement of sutures to control the bleeding areas
Discharge from the emergency department without in-patient endoscopy can be considered for patients with ?
SBP less than 110 mm Hg, pulse rate less than 100 beats/minute, hemoglobin greater than 13 g/dL (men) or 12 g/dL (woman), BUN less than 18.2 mg/dL, and the absence of melena, syncope, heart failure, and liver disease. Overall, requirement for intervention is less than 1%
recent changes in resuscitation of hemorrhagic shock
do not necessarily restore normal vital signs and normal hgb values, as recent studies suggest that restoration of normal vital signs may contribute to increased bleeding
-crystalloid products should be administered sparingly during the initial resuscitation, if excessive can produce coagulopathy, hypothermia, and worsening bleeding
pharmacologic therapy for variceal bleeding aims to to reduce portal pressure and decrease bleeding and involves ?
octreotide (bolus + infusion), somatostatin (infusion), terlipressin (not available in the United States given in boluses), or vasopressin (infusion)
- broad-spec abx ppx: IV 3rd gen cephs or oral FQs
- helpful to begin with PPI in case it is non-variceal in origin
If the patient continues to bleed and remains unstable prior to endoscopy becoming available, options include placement of ?
more permanent options ?
a Sengstaken–Blakemore tube or another type of balloon tamponade device to temporarily control the bleeding, in place for 24 hrs, high rebleeding rates
more permanent:
transjugular intrahepatic portal-systemic shunt (TIPS), endoscopic therapy, or self-expanding intraesophageal stent placement
