gastrointestinal bleeding

Question 1

Gastrointestinal bleeding with tachycardia and hypotension - next step

Answer 1

Bolus of normal saline (or ringer)

the etiology of he bleeding is no as important as fluids

Question 2

Gastrointestinal bleeding - NS vs D5W

Answer 2

D5W does not stay in the vascular space to raise BP as well as N/S

Question 3

MCC of upper GI bleeding

Answer 3

ulcer disease

Question 4

causes of upper GI bleeding

Answer 4

1. ulcer 2. gastritis 3. esophagitis 5. duodenitis

6. cancer 7. varices

Question 5

MCC of lower GI bleeding

Answer 5

diverticulitis

Question 6

causes of lower GI bleeding

Answer 6

1. diverticulitis 2. angiodysplasia (AV malformations)
2. polys or cancer 4. IBD 5. hemorrhoids
3. upper GI with rapid transit from high volume

Question 7

the most important initial management for GI bleeding

Answer 7

assesing BP

Question 8

orthostasis is defined as

Answer 8

more than a 10 point rise in pulse when going from lying down to sitting or standing up or systolic pressure drop of 20 points when sitting up

Question 9

severity of blood loss based on physical findings

Answer 9

15-20% of blood loss –> orthostasis
30% –> pusle more than 100
30% –> systolic BP less than 100

Question 10

the only form of GI bleeding in which physical examination helps determine etiology …. / signs

Answer 10

variceal bleeding

Question 11

variceal bleeding - physical findings

Answer 11

1. signs of liver disease
2. spider angiomata and caput medusa
3. splenomegaly
4. palmar erythema
5. asterixis

Question 12

Initial management of GI bleeding based on

Answer 12

the severity

NOT THE CAUSE

Question 13

GI bleeding - initial diagnostic test? (most important)

Answer 13

is far more important to replace fluids and check Hematocrit, platelet count and coagulation tests (PT INR) than to do an endoscopy

Question 14

red blood in rectum after upper GI bleeding

Answer 14

10% of those with red blood from rectum have high volume upper GI bleeding with rapid transit time

Question 15

GI bleeding - Nasogastric tube

Answer 15

VERY LIMITED BENEFIT –> no therpay delivered through it BUT –> it can rapidly identify upper GI bleeding and hence, who needs ensocopy for banding before colonoscopy

Question 16

GI bleeding - Nasogastric tube sensitivity

Answer 16

70%

if you see bile –> fully sensitive

Question 17

GI bleeding - Nagogastric tube - upper endoscopy

Answer 17

if upper endoscopy will be done anyway –> limited role for NG tube

Question 18

black stool in person with cirrhosis but there is not hematemesis - NG?

Answer 18

an NG showing red blood can tell you to use octreotide for varices and arrange urgent endoscopy for possible banding of varices

Question 19

GI bleeding - fluid resuscitation importance

Answer 19

80% of GI bleeding will stop spontaneously if the fluid resuscitation is adequate
Most patients die of inadequate fluid replacement

Question 20

GI bleeding - additional tests (only names)

Answer 20

1. nuclear bleeding scan
2. angiography
3. capsule endoscopy
4. CT or MRI ob abdomen
5. EKG, lactate level

Question 21

GI bleeding - indication for nuclear bleeding scan

Answer 21

endoscopy unrevealing in a massive acute hemorrhage

LACKS OF ACCURACY

Question 22

GI bleeding - indication for andiography

Answer 22

specific vessel or site of bleeding needs to be identified prior to surgery or embolization of the vessel –> used only in massive non-responsive bleeding

Question 23

GI bleeding - indication for capsule endoscopy

Answer 23

small bowel bleeding –> if upper and lower endoscopy do not show etiology

Question 24

GI bleeding - indication for CT or MRI of abdomen

Answer 24

Not useful in GI bleeding

Question 25

GI bleeding - indication for EKG, lactate

Answer 25

in severe bleeding --> ischemia

Question 26

GI bleeding treatment (only names)

Answer 26

1. fluid replacement 2. Packed red blood cells (if indicated) 3. Fresh frozen plasma (if indicated) 4. platelts (if indicated) 5. octreotide if indicated 6. endoscopy to determine the diagnosis and administer some treatment 7. IV PPI for upper GI bleeding 8. surgery (if indicated)

Question 27

GI bleeding treatment - fluid replacement

Answer 27

high volumes (1-2 L an hout) of saline or Ringer lactte in those with acute severe bleeding

Question 28

GI bleeding treatment - Packed red blood cells

Answer 28

if HcT is below 30 in those who are older or sufer from CAD | if the patients young, transfusion may not be needed until Hct is very low (under20-25)

Question 29

GI bleeding treatment - Fresh frozen plasma

Answer 29

if PT or INR is elevated and active bleeding is occuring

Question 30

GI bleeding treatment - Platelets

Answer 30

if the count is below 50.000 and there is bleeding

Question 31

GI bleeding treatment - Octreotide

Answer 31

for variceal bleeding

Question 32

GI bleeding treatment - endoscopy

Answer 32

to determine the diagnosis and administer some treatment (band varices, cauterise ulcer, infect epinephrine into bleeding gastric vessels)

Question 33

GI bleeding treatment - PPI

Answer 33

IV for Upper GI bleeding

Question 34

GI bleeding treatment - surgery

Answer 34

to remove the site of bleeding if fluids, blood platelets, and plasma will not control the bleeding

Question 35

Administration of platelets to PREVENT bleeding

Answer 35

only if below than 10-20.000

Question 36

GI bleeding - treatment from esophageal and gastric VARICES in addition to Fluids, blood, platelets, plasma (only names)

Answer 36

1. octreotide (somatostatin) 2. Badning 3. TIPS 4. propranolol or nadolol 5. antibiotics

Question 37

GI bleeding from varices - octreotide

Answer 37

(somatostatin) --> to decrease portal pressure

Question 38

GI bleeding from varices - banding

Answer 38

endoscopy obliterates esophageal varices

Question 39

TIPS?

Answer 39

tranjugular intrahepatic portosystemic shunting

Question 40

GI bleeding from varices - TIPS

Answer 40

used to decrease portal pressure in those who are not controlled

Question 41

GI bleeding from varices - propranolol or nadolol

Answer 41

to prevent subsequent epispodes of bleeding | they will not to anything for the current episode of bleeding

Question 42

GI bleeding from varices - antibiotics

Answer 42

to prevent SBP with ascites

Question 43

GI bleeding from varices - sclerotherapy

Answer 43

it is never the right answer if banding is techincally possible