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Flashcards in GI bleed Deck (38):
1

case: lots of conditions, afib
epigastric abdominal pain
no black tarry stool
chronic or acute?

probably acute due to concerning vitals: hypotensive, tachy
if chronic would have compensated

INR: on warfarin
CBC: hgb

1st things to do:
fluid (L bolus)
type/screen for blood transfusion

2

General approach to the GIB

Acute or Chronic?
Hemodynamic instability? ICU if not stable
Medications? OTC? (clopidogrel, warfarin, ASA, etc.) (new drugs: difficult to reverse)
Alcohol use?
Rectal exam? (bright red blood?) NG lavage? (blood? coffee grounds?: UGIB)

3

can reverse warfarin with

FFP and vitamin K+ (long term)

4

GIB tx

Fluids, +/- PRBC (blood transfusion), hold BP Rx, PPI, serial H+H, GI consult, No anticoagulants

5

coffee ground emesis

slide 5, blood, acidity turns it black

6

GIB background/terms

Is this acute or chronic?
Yes, HGB can be as low as 4 without any obvious hemodynamic instability
Hematemesis – bright red blood in vomit, or coffee ground type material
Melena – black, tar like stool

250,000 hospitalizations a year for acute upper GIB
Mortality 4-10%
Hematochezia – BRBPR (bright red blood per rectum) usually lower, but if
Massive upper GIB, can have this

7

osteopathic

esopagus: T2-T8
upper GI: T5-T9, Greater Splanchnic Nerve Celiac Ganglion
middle GI: T10-T11, Lesser Splanchnic Nerve Superior Mesenteric Ganglion
lower GI: T12-L2, Least Splanchnic Verse Inferior Mesenteric Ganglion

8

Acute Upper GI Bleed

Peptic Ulcer Disease: H. pylori

Portal Hypertension:
10-20% of cases
Can be massive due to esophageal or gastric varicose (problem if rupture, can bleed out)

9

Hemodynamic Stabilization

BP Systolic less than 100: high risk
*HR greater than 100 response to acute blood loss, first vital sign of change* (UNLESS on B-blocker)
HCT takes 24-72 hours to equilibrate (trust your gut! pt may have normal levels but look very sick)

10

initial steps

NG tube? Gastric Lavage?
Rectal?
Hemodynamic Stabilization
Two large 18 gauge IV’s
Type and Screen, CBC, INR/PT/PTT, CMP
0.9%NS until blood ready, if needed can use O – blood universal donor
ICU? Central line?

11

HGB goal: old guideline HGB: 10, too many risks from blood transfusions

new guidelines:

7 is threshold now, unless cardiac history then consider goal of greater than 9 (if having brisk bleed with complications, look at pt not numbers)
Platelets more than 50,000


Warfarin? INR high? Give FFP
Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC

12

Uremia? (platelets there but don't stick well together) ESRD Patient?

Consider DDAVP: promotes platelet adhesion

13

Warfarin? INR high?

give FFB

with simple transfusion may dilute out clotting factors: Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC
vitamin K+ long term

14

hx items

Aspirin?
NSAIDS?
NOAC? (?? anticoagulants)
Cirrhosis? (esophageal varices)

WHEN WAS THE LAST DOSE TAKEN?

clopidigrel, ASA take 10-14 days to get out of system (irreversibly bind)

15

Role of Upper endoscopy

Stabilize patient first hemodynamically

if see bleeding vessel, clip it
Cautery, injection, endoclips (fall off on own)
Banding varices (left picture)
video: cauterize with epi

16

pharm therapy

IV PPI: Bolus then drip for 72 hours
Consider PO PPI if low risk features (pantoprazole)

Octreotide

17

Octreotide

Patient’s with esophageal or gastric varices, liver disease, portal HTN
Reduces splanchnic blood flow and portal blood pressures (IV not oral)

18

PPI long term SEs

Potential decrease in non heme iron absorption with PPI has not been well studied

No good evidence to support PPI use affecting bone density or osteoporosis related fractures

~50 cases of hypomagnesemia associated with PPI use
(FDA recommended consider checking magnesium level before starting long term PPI therapy)

19

acute lower GIB

Hematochezia
10% due to upper source
Definition: below ligament of Treitz

20

diverticulosis

can erode into BV and cause bleeding
Acute, painless, large volume possible

21

antioectasia

More common in CKD/ESRD patients

22

other causes of acute lower GIB

Neoplasms
IBD
Anorectal disease (hemorrhoids, fissures)
Ischemic Colitis (older, nonocclusive ischemia, usually self limited)
Radiation induced proctitis

23

L GIB

Exclude upper GIB: NGT, lavage
Rectal Exam
Colonoscopy or sigmoidoscopy: Prep with GoLYTELY 3.8L

24

L GIB dx test: NM PRBC Scan

someone bleeding and don't know where coming from
acts as tracer that will light up with active bleed

If positive, next step is angiography (interventional; can embolize)
Localization is poor, and only helpful if active bleed

25

L GIB dx test: Push Enteroscopy or Capsule Study

successive pictures
sx??

26

L GIB is typically

obscure

27

know slide 20

Crohn's vs UC

28

Crohn's

terminal ileum
"skip" lesions; irregular
transmural inflammation
crampy abd. pain
complic: fistulas, abscess, obstruction
XR: string sign w. barium
slight increase colon ca risk
sx: for stricture complications

29

UC

rectum
proximally continuous
submucosal, mucosal inflammation
bloody diarrhea
complic: hemorrhage, toxic megacolon
XR: lead pipe colon on barium XR
*huge risk of colon Ca* (colonoscopy every few years)
sx is curative

30

transfusions in acute upper GIB

Restrictive strategy group threshold of 7 g/dl
Goal 7-9
Liberal group threshold of 9 g/dl
Goal 9-11
Mortality at 45 days lower in restrictive strategy group 23/444 vs. 41/445

Subgroup with cirrhosis, risk of death was lower in restrictive strategy group 15/139 vs. 25/138

31

Novel Anticoagulants in GIB

Pradaxa – dabigatran
Xarelto – rivaroxaban
Eliquis - apixaban

expensive, but do not have to check INR!
active w.in hrs (vs. coumadin)
advantage if bleeding, wear off quickly as well

32

3 meds work as factor Xa inhibitor
??inhibit thrombin

diff than warfarin
Pradaxa – dabigatran blocks thrombin

33

novel anticoagulants

risk of GIB is a little higher
hemorrhagic stroke risk is lower

34

When to Resume Warfarin After GIB

7 days

Restarting warfarin after 7 days was NOT associated with increased risk of GIB, but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption.

35

sometimes elderly pts on steroids/NSAIDS put on pentoprozol? to ??

prevent risk of bleed
(sometimes don't want to go on due to risk of C. diff)

36

recommendations for ASA

Use of low dose aspirin for cardiovascular prophylaxis associated with 2-4 fold increase in upper gastrointestinal events (81 mg just as effective as 325 mg, less GIB risk)
AHA recommends low dose aspirin in patient with 10 year cardiovascular risk > or = 10%
INR goal of 2-2.5 is recommended for:
Combination of aspirin and heparin/LMWH/warfarin or clopidogrel

37

which ulcer more pain with eating??

what else?

Gastric ulcer – Greater with meals (pain)
Duodenal ulcer – Decreases with meals (pain)
Ischemic colitis – post-prandial abdominal pain, older patient, hematochezia

38

medications

H2 blockers – famotidine, ranitidine – Block H2 receptors of parietal cells
PPI’s – omeprazole, pantoprazole (high risk C.diff) – Inhibit H+/K+ ATPase in parietal cells
? Low magnesium levels long term use, higher risk of C diff

Magnesium – Makes you go, take for constipation
Aluminium – minimum amount of feces, take for diarrhea
Osmotic laxatives – PEG, lactulose