GI Bleeding

Question 1

ligament of tretz

Answer 1

proximal to ligament of treitz- upper GI bleeding. distal to ligament of treitz- lower GI bleeding

Question 2

ligament of treitz separates

Answer 2

duodenum from jejunum

Question 3

UGI bleeding prognosis

Answer 3

self limited in 80%. remaining 20%- medical therapy and EGD

Question 4

causes of acute UGI bleeding

Answer 4

PUD (most common), portal HTN, mallory weiss tear, vascular anomalies, gastric neoplasm, erosive gastritis, erosive esophagitis

Question 5

incidence of bleeding from peptic ulcer dz is decreasing d/t

Answer 5

tx of h. pylori and tx with PPI’s

Question 6

tx of portal hypertension

Answer 6

IV octrotide infusion

Question 7

portal HTN causing acute UGI bleeding most often d/t

Answer 7

varices (esophageal, gastric, duodenal)

Question 8

tears at the GE junction d/t retching

Answer 8

mallory-weiss tears

Question 9

mallory -weiss tears most commonly occur in what type of patients?

Answer 9

alcoholics and bulemics

Question 10

vascular anomalies causing acute UGI bleeding include

Answer 10

angioectasias (1-10 mm dialted submucosal vessels), telangectasias (dilated venules), and Dieulafoy’s lesions (dilated artery in proximal stomach)

Question 11

angioectasias most common in

Answer 11

right colon

Question 12

erosive gastritis causing acute UGI bleeds d/t

Answer 12

NSAIDS, alcohol, or severe medical or surgical illness

Question 13

erosive esophagitis causing acute UGI bleeds (rare) results form

Answer 13

chronic GERD

Question 14

Is hgb/hct helpful in determing severity in GI bleeding?

Answer 14

may take 1-3 days to equilibrate so do not rely on this value

Question 15

management/tx of acute UGI bleed

Answer 15

strat with looking at VS (Hgb, BP, PP, HR,, UO, MS). if normal, check orthostatics. Get labs- CBC, PT, chem 7, LFT, type and screen. Hook up 2 large bores- IVF. type and cross 2-4 units if severe bleeding. CVP monitoring, NG tube. risk stratification to determine EGD within 2-4 hours or within 24 hours

Question 16

If need to clear stomach in case of upper GI bleed

Answer 16

don’t do gastric lavage. use IV erythromycin to clear stomach

Question 17

NG aspirate of red blood or coffee grounds=

Answer 17

confirms UGI source of bleeding.

Question 18

Bright red blood vs. clear aspirate from NG tube

Answer 18

high risk of complications. if clear= duodenal source of bleeding

Question 19

blood replacement in acute UGI bleeding

Answer 19

Hgb should raise 1 gram for each unit of PRBC’s given. In massive bleeding, give 1 unit FFP for every 5 units of PRBC’s.

Question 20

when is FFP given in acute UGI bleeding

Answer 20

If massive bleeding or if patient with coagulopathy

Question 21

when are platelets transfused in acute UGI bleeding?

Answer 21

if less than 50,000 or if patient has taken ASA or clopidogrel

Question 22

when is DDAVP given in acute UGI bleeding

Answer 22

uremic patients

Question 23

Hgb should be kept in range of ___ in acute UGI bleeding replacement

Answer 23

6-10

Question 24

low risk- acute UGI bleeding

Answer 24

no evidence of active bleeding. admit to GMB or stepdown. EGD within 24 hours.

Question 25

high risk indications and management - acute UGI bleeding

Answer 25

hematemesis, bright red blood per NG, shock, advanced liver disease, hypovolemia unresponsive to resuscitation. serious comorbid disease. ADMIT TO ICU, EGD WITHIN 2-4 HOURS

Question 26

History is only 40% accurate, so __ used to identify source of bleeding in acute UGI bleeds

Answer 26

EGD

Question 27

meds for acute UGI bleeding

Answer 27

IV "prazole" (PPI) or high dose oral PPI prior to EGD. intra-arterial embolization, TIPS, surgery

Question 28

95% of LGI bleeding is from

Answer 28

colon

Question 29

most common cause of LGI bleed

Answer 29

diverticulosis

Question 30

most common cause of UGI bleed

Answer 30

peptic ulcer disease

Question 31

what increases risk of diverticulosis

Answer 31

ASA and NSAIDS

Question 32

causes of acute LGI bleeding

Answer 32

diverticulosis, angioectasias, neoplasms, IBD, anorectal disease, ischemic colitis, infectious colitis

Question 33

most common to see those over 70 yo and in patients with renal failure (acute lower Gi bleeding cause)

Answer 33

angioectasias

Question 34

BRBPR in patients over 50, PAINLESS

Answer 34

diverticulosis

Question 35

most common diagnostic instruments to determine source of bleeding in UGI and LGI bleeds

Answer 35

EGD, colonoscopy. If massive LGI bleeding in hemodynamiccally unstable patient, do angiography

Question 36

diarrhea w/intermittent hematochemize, abd pain, tenesmus, urgency of stool

Answer 36

IBD

Question 37

bright red blood that drips into toilet after BM

Answer 37

anorectal disease (hemorrhoids, fissures, stercoral ulcers)

Question 38

where does ischemic colitis occur

Answer 38

"watershed" areas of colon

Question 39

Diagnosis of acute lower GI bleed

Answer 39

1. exclude UGI source. 2 anoscopy/sigmoidoscopy. 3. colonoscopy 4. tagged RBC scan 5. angiography 6. small intestine push enteroscopy 7. capsule endoscopy

Question 40

how to exclude UGI source in diagnosis of LGI bleed

Answer 40

if unstable patient, NG tube for aspiration. EGD performed in patients with hematochezia and hemodynamic instability

Question 41

If patient presents with LGI bleeding, is younger than 45, and has small volume bleeding-->

Answer 41

anoscopy/sigmoidoscopy to look for anorectal dz, IBD, infectious colitis

Question 42

bowel prep done in most cases for colonoscopy- this is performed within 24 hours vs. 2 hours if...

Answer 42

24 hours if bleeding minimal. within 2 hours of prep if bleeding severe

Question 43

embolization of bleeding vessel effectively stops bleeding in 95%. but complication rate 5%-

Answer 43

ischemic colitis

Question 44

acute lower GI bleeding diagnostic instrument used to identify lesions in small intestine

Answer 44

push enteroscopy

Question 45

negatives of capsule endoscopy

Answer 45

gretaer potential for hemorrhage, hard to locazline bleeding site

Question 46

tx for acute LGI bleeding

Answer 46

colonoscopy (cautery), angiography with embolization, surgical tx

Question 47

surgical tx indications in acute LGI bleeding tx

Answer 47

ongoing bleeding, or if transfusion requirements are more than 6 units in 24 hours, or if 2 or more hospitalizations for diverticular hemorrhage

Question 48

segmental colon resection vs. subtotal colectomy

Answer 48

if preoperative localization done by antiography or tagged RBC scan, then segmental colon resection. if source of LGI bleed cannot be localized, do subtotal colectomy

Question 49

obscure Gi bleeding -

Answer 49

bleeding of unknown origin that persists or recurs after negative EGD and colonoscopy

Question 50

obscure GI bleeding most commonly arises from lesions in

Answer 50

small intestine. (1/3 are missed lesions of stomach or colon)

Question 51

etiology of Obscure GI bleeding

Answer 51

if over 40, NSAID induced or angioectasias. if uncer 40, SB neoplasm, crohn's, celiac dz, meckel's diverticulum

Question 52

evaluation of younger patients and symptomatic older patients for obscure GI bleeding

Answer 52

EGD and colonoscopy to r/o missed lesion, capsule endoscopy if scopes are negative. add meckel's scan if younger than 30

Question 53

occult Gi bleeding is how much

Answer 53

less than 100 ml/day (not apparent to patient)

Question 54

occult GI bleeding identified by

Answer 54

FOBT or iron deficiency anemia (serum ferritin less than 30-45 mcg/L

Question 55

occult GI bleeding that is asymptomatic , positive FOBT

Answer 55

colonoscopy

Question 56

occult GI bleeding that is symptomatic, positive FOBT

Answer 56

colonoscopy and EGD

Question 57

if patient is greater than 60 without symptoms of occult GI bleeding, mange---

Answer 57

trial iron supplementation and observe. if no response, pursue a small bowel source

Question 58

if patient greater than 60 and symptomatic or less than 60, manage...

Answer 58

pursue evaluation of small bowel

Question 59

occult Gi bleeding- STOP

Answer 59

nsaids, asa, clopidogrel