EXAM #2: GI BLEEDING Flashcards Preview

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Flashcards in EXAM #2: GI BLEEDING Deck (49)
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1
Q
What delineates between upper and lower GI bleeding?
A
Trietz angle
2
Q
What does occult bleeding indicate?
A
Slow bleeding/ low volume
3
Q
What is melena and indication of?
A
UGI bleed
- Esophagus
- Stomach
- Duodenum
4
Q
What is hematochezia?
A
Dark red blood or dark maroon colored blood
5
Q
What does hematochezia indicate?
A
- Usually lower GI bleed
- Potentially v. fast UGI
6
Q
What do you need to remember about stool color?
A
DO NOT USE STOOL COLOR TO R/O ORIGIN
7
Q
What is the typical manifestation of chronic GI bleeding?
A
Anemia
8
Q
What is the typical presentation of acute GI bleeding?
A
Signs and symptoms of volume loss
9
Q
How much does the blood pressure need to drop when changing positions for positive orthostatic changes?
A
20 mm/Hg (systolic), also:
- 10 mm/Hg diastolic
- HR increase 10 bpm
10
Q
What change will be heard with bowel sounds in a UGI?
A
Increased bowel sounds--blood is an irritant
11
Q
Review the first case study in the ppt. How sick is the patient? Why?
A
V. sick
- Hx of HTN and hypotensive
- Beta blocker and tachycardia
- Orthostatic changes

****Significant hypovolemia*****
12
Q
What is the DDx of a UGI?
A
1) PUD
2) Erosive esophagitis/ gastritis/ duodenitis i.e. NSAIDs or H. pylori
3) Gastroesophageal varices
13
Q
What is GAVE?
A
Gastric antral vascular ectasia
- Dilated small vessels in the antrum of the stomach
14
Q
What is the buzzword associated with GAVE?
A
Watermelon Stomach
15
Q
What is a cause of UGI that is associated with very high mortality?
A
Aortoenteric fistula
- Abnormal connection between aorta and intestines
- Typically occurs secondary to AAA repair
16
Q
What is a Dieulafoy lesion?
A
- Abnormal arterial GI vessel
- V. superficial
- Life-threatening bleeding results
17
Q
What is the most common etiology of lower GI bleed, especially in the elderly?
A
Diverticulosis
18
Q
List the three most common causes of Lower GI Bleed.
A
1) Diverticulosis
2) Angiectasias
3) Hemorrhoids
19
Q
What two diseases increase the rate of Angiectasias?
A
1) AAA
2) Renal failure
20
Q
What is Osler-Weber Rendu?
A
Genetic disorder that causes diffuse vascular dysplasia
- Increases the risk for bleeding
- Also known as Hereditary Hemorrhagic Telangectasia (HHT)
- Autosomal dominant inheritance
21
Q
What two diseases can cause hyperpigmentation of the oral mucosa that can predispose one to GI bleeding?
A
1) Osler-Weber Rendu/ HHT
2) Peutz-Jeghers Syndrome
22
Q
What must be performed during the PE if you suspect volume loss in a patient?
A
Orthostatic vital signs
23
Q
What are the predictors of UGI?
A
1) Less than 50 y/o
2) Melenic stool
3) BUN/Creatinine ratio greater than 30
24
Q
What are the indications for an NG tube in the face of GI Bleeding?
A
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.
25
Q
How do you begin the resuscitation of a patient with significant hypovolemia?
A
1) IV access (bilateral large bore)
2) Crystalloids
3) Anticipate need for blood transfusion
26
Q
When do you need to transfuse a patient with a GI bleed?
A
Hgb less than or equal to 7 g/dL
27
Q
What is AIMS65? What is it used for?
A
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
28
Q
What is the Rockall Scoring System?
A
Predictor of mortality in UGIB
29
Q
What is the utility of the Blatchford Score?
A
This score predicts the NEED for ENDOSCOPIC THERAPY
30
Q
Once you have resuscitated a patient with a non-variceal UGIB, how can you start pharmoctherapy?
A
IV PPI
- Facilitates clot formation
- stop once diagnostic endoscopy has been performed
31
Q
What procedure is always indicated for patients with a suspected UGIB?
A
Endoscopy (within 24 hours)
32
Q
What is the purpose of endoscopoy?
A
1) Confirmation of diagnosis
2) Risk stratification
3) Speeds access to therapy
33
Q
When is endoscopic therapy required? What determines this requirement?
A
Stigmata i.e. characteristics:
1) Active bleeding
2) Nonbleeding visible vessel

****Treating these is done to prevent rebleeding*****
34
Q
What are the stigmata that don't require endoscopic therapy?
A
1) Adherent clot
2) Flat pigmented spot
3) Clean base
35
Q
How is hemostasis achieved with endoscopy?
A
1) Epi injection
2) Electrocoagulation
3) Clipping (mechanical)

Often combination therapy is employed.
36
Q
In a patient with CAD that is on ASA, when should ASA be re-started following a UGIB?
A
As soon as the bleeding as been resolved
37
Q
What is the mnemonic for remembering the clinical features of variceal bleeding?
A
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
38
Q
What is the mnemonic to remember how to manage variceal bleeding?
A
VARICEALB

V= Vasoconstrictor
A= Antibiotics
R= Resuscitation
IC= ICU level care
E= Endoscopy
AL= Alternative
B= Beta blockers
39
Q
What is the common vasoconstrictor used to treat Variceal bleeding?
A
Terlipressin
40
Q
Why are ABX used in Variceal bleeding?
A
- Reduce infection
- Reduces rebleeding
41
Q
When should endoscopy be performed in variceal bleeding?
A
ASAP after resuscitation
42
Q
What is the "alternative" rescue technique used to treat variceal bleeding?
A
TIPS

Transjugular Intrahepatic Portosystemic Shunt
43
Q
What type of beta-blocker should be used to treat Variceal bleeding?
A
Nonselective
44
Q
What are the predictors of severe LGIB?
A
1) HR greater than 100
2) SBP less than 115
3) Syncope
4) Nontender abdominal exam
5) 2+ comorbid conditions
45
Q
What are the three major risk factors for mortality in LGIB?
A
1) Age
2) Intestinal ischemia
3) Comorbid illness
46
Q
What do you do a colonoscopy in LGIB?
A
Unlike UGIB, urgent colonscopy is NOT required
47
Q
What is the alternative study to a colonscopy in a LGIB?
A
Angiography

Note that the advantage of this is that IR can coil this and provide definitive treatment.
48
Q
When is surgery required for LGIB?
A
1) SEVERE bleeding
- Requires more than 6 units of blood
49
Q
What procedure is indicated in obscure GI bleeding?
A
Capsule endoscopy