EXAM #2: GI BLEEDING

Question 1

What delineates between upper and lower GI bleeding?

Answer 1

Trietz angle

Question 2

What does occult bleeding indicate?

Answer 2

Slow bleeding/ low volume

Question 3

What is melena and indication of?

Answer 3

UGI bleed
- Esophagus
- Stomach
- Duodenum

Question 4

What is hematochezia?

Answer 4

Dark red blood or dark maroon colored blood

Question 5

What does hematochezia indicate?

Answer 5

- Usually lower GI bleed
- Potentially v. fast UGI

Question 6

What do you need to remember about stool color?

Answer 6

DO NOT USE STOOL COLOR TO R/O ORIGIN

Question 7

What is the typical manifestation of chronic GI bleeding?

Answer 7

Anemia

Question 8

What is the typical presentation of acute GI bleeding?

Answer 8

Signs and symptoms of volume loss

Question 9

How much does the blood pressure need to drop when changing positions for positive orthostatic changes?

Answer 9

20 mm/Hg (systolic), also:
- 10 mm/Hg diastolic
- HR increase 10 bpm

Question 10

What change will be heard with bowel sounds in a UGI?

Answer 10

Increased bowel sounds--blood is an irritant

Question 11

Review the first case study in the ppt. How sick is the patient? Why?

Answer 11

V. sick
- Hx of HTN and hypotensive
- Beta blocker and tachycardia
- Orthostatic changes

****Significant hypovolemia*****

Question 12

What is the DDx of a UGI?

Answer 12

1) PUD
2) Erosive esophagitis/ gastritis/ duodenitis i.e. NSAIDs or H. pylori
3) Gastroesophageal varices

Question 13

What is GAVE?

Answer 13

Gastric antral vascular ectasia
- Dilated small vessels in the antrum of the stomach

Question 14

What is the buzzword associated with GAVE?

Answer 14

Watermelon Stomach

Question 15

What is a cause of UGI that is associated with very high mortality?

Answer 15

Aortoenteric fistula
- Abnormal connection between aorta and intestines
- Typically occurs secondary to AAA repair

Question 16

What is a Dieulafoy lesion?

Answer 16

- Abnormal arterial GI vessel
- V. superficial
- Life-threatening bleeding results

Question 17

What is the most common etiology of lower GI bleed, especially in the elderly?

Answer 17

Diverticulosis

Question 18

List the three most common causes of Lower GI Bleed.

Answer 18

1) Diverticulosis
2) Angiectasias
3) Hemorrhoids

Question 19

What two diseases increase the rate of Angiectasias?

Answer 19

1) AAA
2) Renal failure

Question 20

What is Osler-Weber Rendu?

Answer 20

Genetic disorder that causes diffuse vascular dysplasia
- Increases the risk for bleeding
- Also known as Hereditary Hemorrhagic Telangectasia (HHT)
- Autosomal dominant inheritance

Question 21

What two diseases can cause hyperpigmentation of the oral mucosa that can predispose one to GI bleeding?

Answer 21

1) Osler-Weber Rendu/ HHT
2) Peutz-Jeghers Syndrome

Question 22

What must be performed during the PE if you suspect volume loss in a patient?

Answer 22

Orthostatic vital signs

Question 23

What are the predictors of UGI?

Answer 23

1) Less than 50 y/o
2) Melenic stool
3) BUN/Creatinine ratio greater than 30

Question 24

What are the indications for an NG tube in the face of GI Bleeding?

Answer 24

1) Hematemesis
2) Frank hematochezia

Note that 15-20% of patients with upper GI bleeding will have a negative NG aspirate--keep in differential even if negative.

Question 25

How do you begin the resuscitation of a patient with significant hypovolemia?

Answer 25

1) IV access (bilateral large bore)
2) Crystalloids
3) Anticipate need for blood transfusion

Question 26

When do you need to transfuse a patient with a GI bleed?

Answer 26

Hgb less than or equal to 7 g/dL

Question 27

What is AIMS65? What is it used for?

Answer 27

Risk score that predicts mortality, length of stay, and cost
- Albumin less than 3
- INR greater than 1.5
- AMS
- Systolic less than 90 mm/Hg
- 65+ y/o

Question 28

What is the Rockall Scoring System?

Answer 28

Predictor of mortality in UGIB

Question 29

What is the utility of the Blatchford Score?

Answer 29

This score predicts the NEED for ENDOSCOPIC THERAPY

Question 30

Once you have resuscitated a patient with a non-variceal UGIB, how can you start pharmoctherapy?

Answer 30

IV PPI
- Facilitates clot formation
- stop once diagnostic endoscopy has been performed

Question 31

What procedure is always indicated for patients with a suspected UGIB?

Answer 31

Endoscopy (within 24 hours)

Question 32

What is the purpose of endoscopoy?

Answer 32

1) Confirmation of diagnosis
2) Risk stratification
3) Speeds access to therapy

Question 33

When is endoscopic therapy required? What determines this requirement?

Answer 33

Stigmata i.e. characteristics:
1) Active bleeding
2) Nonbleeding visible vessel

****Treating these is done to prevent rebleeding*****

Question 34

What are the stigmata that don't require endoscopic therapy?

Answer 34

1) Adherent clot
2) Flat pigmented spot
3) Clean base

Question 35

How is hemostasis achieved with endoscopy?

Answer 35

1) Epi injection
2) Electrocoagulation
3) Clipping (mechanical)

Often combination therapy is employed.

Question 36

In a patient with CAD that is on ASA, when should ASA be re-started following a UGIB?

Answer 36

As soon as the bleeding as been resolved

Question 37

What is the mnemonic for remembering the clinical features of variceal bleeding?

Answer 37

1/3
- Occurs in 1/3 of patients with cirrhosis
- 1/3 are initially fatal
- 1/3 rebleed in 6 weeks
- 1/3 survive a year

Question 38

What is the mnemonic to remember how to manage variceal bleeding?

Answer 38

VARICEALB

V= Vasoconstrictor
A= Antibiotics
R= Resuscitation
IC= ICU level care
E= Endoscopy
AL= Alternative
B= Beta blockers

Question 39

What is the common vasoconstrictor used to treat Variceal bleeding?

Answer 39

Terlipressin

Question 40

Why are ABX used in Variceal bleeding?

Answer 40

- Reduce infection
- Reduces rebleeding

Question 41

When should endoscopy be performed in variceal bleeding?

Answer 41

ASAP after resuscitation

Question 42

What is the "alternative" rescue technique used to treat variceal bleeding?

Answer 42

TIPS

Transjugular Intrahepatic Portosystemic Shunt

Question 43

What type of beta-blocker should be used to treat Variceal bleeding?

Answer 43

Nonselective

Question 44

What are the predictors of severe LGIB?

Answer 44

1) HR greater than 100
2) SBP less than 115
3) Syncope
4) Nontender abdominal exam
5) 2+ comorbid conditions

Question 45

What are the three major risk factors for mortality in LGIB?

Answer 45

1) Age
2) Intestinal ischemia
3) Comorbid illness

Question 46

What do you do a colonoscopy in LGIB?

Answer 46

Unlike UGIB, urgent colonscopy is NOT required

Question 47

What is the alternative study to a colonscopy in a LGIB?

Answer 47

Angiography

Note that the advantage of this is that IR can coil this and provide definitive treatment.

Question 48

When is surgery required for LGIB?

Answer 48

1) SEVERE bleeding
- Requires more than 6 units of blood

Question 49

What procedure is indicated in obscure GI bleeding?

Answer 49

Capsule endoscopy