GI Bleed

Question 1

How does upper GI bleeding (UGIB) usually present?

Answer 1

As hematemesis (blood or coffee-ground emesis) or melena (black, tarry stool).

Question 2

What is the most common presentation of lower GI bleeding (LGIB)?

Answer 2

Hematochezia (frank blood per rectum or red or maroon-colored stool).

Question 3

What are the inpatient mortality rates for UGIB and LGIB?

Answer 3

UGIB is estimated at 10% and LGIB at 4%.

Question 4

What are the goals for evaluating and managing a patient with possible GI bleeding?

Answer 4

To stabilize the patient, confirm the gut is the origin of the bleeding, determine the likely site and nature of the bleeding, and provide appropriate therapy.

Question 5

What was the trend in hospitalizations for GI hemorrhage related to peptic ulcer disease (PUD) from 2000 to 2011?

Answer 5

Decreased by 66% in the United States, mainly due to antimicrobial treatment for Helicobacter pylori.

Question 6

What is a significant risk factor for PUD-associated bleeds?

Answer 6

Nonsteroidal antiinflammatory drug (NSAID) use.

Question 7

What does UGIB originate from?

Answer 7

Proximal to the ligament of Treitz.

Question 8

What are the most common causes of UGIB?

Answer 8

Peptic ulcer disease (PUD), erosive disease, and esophageal varices.

Question 9

What are common causes of UGIB in children?

Answer 9

Mallory-Weiss tears, ulcers, gastritis, and esophagitis.

Question 10

What does LGIB originate from?

Answer 10

Distal to the ligament of Treitz.

Question 11

What is the most common cause of bleeding from the large bowel?

Answer 11

Diverticulosis.

Question 12

What are common causes of pediatric LGIB?

Answer 12

Anal fissures, Meckel diverticulum, allergic colitis, enteric infections, and polyps.

Question 13

What clinical indicators are more reliable than emesis color for gauging bleeding severity?

Answer 13

Clinical indicators of shock.

Question 14

What symptoms may indicate significant blood loss?

Answer 14

Lightheadedness and atypical symptoms of acute coronary syndrome (ACS).

Question 15

What signs should be assessed in patients with acute GI bleeding?

Answer 15

Signs of shock, including tachycardia and hypotension.

Question 16

What initial lactate level is associated with increased mortality?

Answer 16

Greater than 2.5 mmol/L.

Question 17

What does an INR greater than 1.5 indicate?

Answer 17

Increased inpatient mortality and the need for intensive care unit (ICU) admission.

Question 18

What is the preferred imaging modality for significant UGIB?

Answer 18

Endoscopy.

Question 19

What is the role of angiography in LGIB?

Answer 19

It can localize and embolize bleeding sources in unstable patients.

Question 20

What is the sensitivity of nuclear scintigraphy for detecting bleeding?

Answer 20

It can detect bleeding as slow as 0.05 mL/min but is not indicated in acute GI bleeding.

Question 21

What is the first step in managing patients with acute UGIB?

Answer 21

Determining if the patient is having a massive GI bleed or not.

Question 22

How is a massive GI bleed defined?

Answer 22

Ongoing active bleed (hematemesis or hematochezia) and a shock index of 0.9 or greater.

Question 23

What is the primary goal of volume resuscitation in massive GI bleed?

Answer 23

Maintenance of adequate tissue perfusion.

Question 24

What initial treatment should be given to patients with a massive GI bleed?

Answer 24

Placement of at least two large-bore IV catheters, infusion of crystalloids, and transfusion of uncrossmatched blood.

Question 25

What is the recommended bolus infusion of crystalloids for massive GI bleed?

Answer 25

2 L over 30 minutes with a balanced isotonic solution.

Question 26

What is the second step in the management of acute GI bleeding?

Answer 26

Attempting to localize the bleed as either UGIB or LGIB.

Question 27

What characterizes high-risk patients with GI bleeding?

Answer 27

Ongoing bleeding requiring interventions such as endoscopy, surgery, or continued blood transfusion.

Question 28

What does a Glasgow-Blatchford score of 7 or greater indicate?

Answer 28

80.4% sensitivity in predicting the need for endoscopic treatment.

Question 29

What is the significance of a Glasgow-Blatchford score of 1 or less?

Answer 29

Identifies patients at low risk of rebleeding who may be appropriate for discharge.

Question 30

What does empiric treatment for acute GI bleeding involve?

Answer 30

Prompt resuscitation, consideration of blood or platelet transfusion, pharmacologic therapy, and early consultation.

Question 31

What is the goal for crystalloid fluid infusion in patients showing signs of hemodynamic compromise?

Answer 31

Deliver 2 L over the first 30 minutes.

Question 32

When should intubation be considered in patients with massive UGIB?

Answer 32

For patients with uncontrollable hematemesis, respiratory distress, or severe shock.

Question 33

What is the recommended hemoglobin threshold for transfusion in stable patients without CAD?

Answer 33

At least 8 g/dL.

Question 34

What is the recommended transfusion threshold for patients with known CAD?

Answer 34

Minimum hemoglobin greater than 9 g/dL.

Question 35

What is the role of fresh frozen plasma (FFP) in patients with liver disease and GI bleeding?

Answer 35

Controversial; not recommended unless receiving massive transfusion.

Question 36

What is the recommended platelet count to maintain in patients with UGIB?

Answer 36

Greater than 50,000 platelets/μL.

Question 37

What is the mainstay pharmacologic therapy for acute GI bleeding?

Answer 37

Proton pump inhibitors (PPIs).

Question 38

What is the recommended dose of IV omeprazole for acute GI bleeding treatment?

Answer 38

80 mg IV followed by a continuous infusion of 8 mg/h.

Question 39

What agents are recommended for patients with variceal bleeding?

Answer 39

Splanchnic vasoconstrictors such as somatostatin and octreotide.

Question 40

What prophylactic antibiotics are recommended for patients with UGIB and cirrhosis?

Answer 40

Fluoroquinolones or a third-generation cephalosporin.

Question 41

What is the purpose of balloon tamponade in GI bleeding management?

Answer 41

Indicated for rapidly exsanguinating patients when endoscopy is not promptly available.

Question 42

What should be done for patients with significant UGIB requiring early consultation?

Answer 42

Consultation with a gastroenterologist for consideration of endoscopy.

Question 43

What is the recommendation for patients with brisk LGIB?

Answer 43

Emergent consultation with an interventional radiologist for possible selective embolization.

Question 44

Common causes of GIB in adults and children

Answer 44

Question 45

Diagnostic and management algorithm for acute GIB

Answer 45

Question 46

Describe Glasgow-Blatchford Score

Answer 46

Question 47

What is Heyde's syndrome?

Answer 47

## Footnote Heyde's syndrome is a rare condition that causes aortic stenosis and gastrointestinal bleeding. A clinical triad of severe aortic stenosis, a history of recurrent gastrointestinal bleeding, and an endoscopic diagnosis of angiodysplasia

Question 48

Causes of Pediatric GIB

Answer 48

Question 49

Mimickers of GI bleed

Answer 49

Question 50

What labs to send for GI bleed evaluation?

Answer 50

CBC, lytes, urea (BUN), Cr, albumin ​ LFT’s, lipase​ inr, ptt​ Group + screen​ Vbg + lactate​ TROP + ECG​ ± calcium, fibrinogen

Question 51

At what ratio is BUN/Cr specific for GIB

Answer 51

blood urea nitrogen (BUN) to creatinine (Cr) ratio of greater than 35 is​ 90% specific for UGIB​ ​ However, the BUN:Cr ratio is poorly sensitive and​ cannot be used to rule out UGIB

Question 52

How does FOBT work? Name some false positives and negatives.

Answer 52

When hydrogen peroxide drips onto guaic paper, an oxidative reaction turns the paper blue. uses the pseudoperoxidase activity found on Hb​ Blood = blue False positives: Colchicine, iodine, boric acid, red meat False negatives: Vit C, Citrus fruits ## Footnote Imitators of melena: iron, bismuth and black foods like black licorice

Question 53

Order of priority of IV medications in upper GI bleed emergencies

Answer 53

1. Ceftriaxone 1 g IV for all cirrhotics 2. Octreotide 50 μg bolus + 50 μg/hr infusion for all UGIB patients 3. Erythromycin 250mg, 30 minutes prior to endoscopy for suspected peptic ulcer 4. PPI e.g. Pantaprazole 80 mg IV bolus (no infusion necessary) – once you’ve given everything else, if the endoscopist asks for it ## Footnote Antibiotics have mortality benefit, NNT 22 for death, NNT 4 for infection Octreotide is splanchnic vasoconstrictor prevents rebleeding both variceal and non variceal bleed Erythromycin improves gastric motility and visualization of GI mucosa, NNT 10 to prevent repeat endo PPI has no mortality benefit

Question 54

Management steps in GIB

Answer 54

Question 55

Airway Mx in UGIB

Answer 55

Question 56

Complications of Massive Transfusion Protocol

Answer 56

## Footnote Definition:Massive transfusion was traditionally defined as the administration of more than 10 units of PRBCs over 24 hours, but a more practical and efficacious application of the concept is the transfusion of 3 units of PRBCs over an hour or the use of 4 components over 30 minutes.

Question 57

What are the different types of tubes used in GIB ?

Answer 57

Question 58

What are the indications and contraindications for using ballon tamponade in GIB?

Answer 58

Question 59

Common complications of ballon tamponade

Answer 59

Question 60

Characteristic of patients with high risk for GIB

Answer 60

Question 61

What is Oakland score?

Answer 61

Used in patients with LGIB to help determine safe discharge home

Question 62

What is the low risk criteria for d/c home?

Answer 62

Question 63

Common reversal agents for bleeding

Answer 63

Question 64

Commonly used plasma products

Answer 64