GI Bleeding

Question 1

Clinical Presentation
Initial evaluation & resuscitation
Assess what? Use what?
Access required?
Lab to obtain for resuscitation?
Monitor what labs?
Transfuse when?
Supplement what electrolyte? why?

Answer 1

Assess severity of bleeding; continuous monitoring of HD parameters to guide resuscitation
2 large bore IVs immediately
Type & Cross
CBC, Coags, Ca+
Ca+; citrate in blood products binds with Ca+ leading to hypocalcemia

Question 2

Estimating Blood Loss
Class I
Loss of how much total blood volume?
Clinical findings include?

Answer 2

</= 15%
may be minimal or absent d/t compensation of transcapillary refill

Question 3

Estimating Blood Loss
Class II
Loss of how much total blood volume?
S/Sx?
Compensatory mechanism activated?
May see drop in what due to what?

Answer 3

15-30%
orthostatic changes in HR, BP
vasoconstriction maintains flow to vital organs
UOP; Splanchnic flow

Question 4

Estimating Blood Loss
Class III
Loss of how much total blood volume?
Onset of what?
S/Sx?

Answer 4

30-40%
decompensated hypovolemic shock
hypotension, decreased UOP

Question 5

Estimating Blood Loss
Class IV
Loss of how much total blood volume?
S/Sx?
Changes may be what?

Answer 5

> 40%
hypotension & oliguria more profound (UOP < 5ml/hr)
irreversible

Question 6

Resuscitation of hypovolemic shock goal

Answer 6

maintain DO2 to tissues & sustain aerobic metabolism
Support CO
Correct Hgb deficits

Question 6

How much IV crystalloid infusion to replace blood loss?
What type to use?
What type of blood to use during resuscitation?

Answer 6

3ml/1ml blood loss
LR 1-2L initially
NS (be aware of possible hyperchloremic acidosis)
O-

Question 7

Transfuse for hgb < what?
Transfuse for Hgb < what for cardiac or ortho surgery?

Answer 7

7
8

Question 8

Hx and Risk Factors for GI Bleeding
elderly?
Younger?
other risk factors?

Answer 8

Diverticulosis, vascular ectasia, ischemic colitis
Varices, ulcers, esophagitis
previous bleeding/GI dz, previous surgery, underlying dz

Question 9

Meds that can cause GI bleeding

Answer 9

NSAIDs
ASA

Question 10

Clinical Findings for GI bleeding

Answer 10

Change in bowel habits
Weight loss
Abdominal pain
Hematemesis
Coffee-ground emesis
Bloody NG aspirate
Melena
Hematochezia

Question 11

Upper GI bleeding is from where?
Endoscopy recommended within what time frame?

Answer 11

esophagus, stomach, duodenum
24 hrs

Question 12

Differential Dx for Upper GI bleeding
Nonvariceal

Answer 12

peptic ulcer
Mallory-Weiss tear
Erosive esophagitis or duodenitis
esophagitis
dieulafoy’s lesion
angiodysplasia
malignancy

Question 13

Differential Dx for Upper GI bleeding
Variceal

Answer 13

esophageal
gastric

Question 14

Clinical Manifestations of Peptic Ulcer Dz
Recurrent pain with periods of remission described how?

Answer 14

usually epigastric
may radiate to back
burning
painful hunger
may be relieved by, worsened by, or unrelated to food
nocturnal pain several hrs after late meal c/w ulceration

Question 15

Clinical Manifestations of Peptic Ulcer Dz

Answer 15

heartburn/acid reflux into throat c/w GERD
N/V may be present

Question 16

Complications of PUD

Answer 16

Bleeding, perforation

Question 17

When to test for H. Pylori?

Answer 17

Active PUD
Mucosa associated lymphoid tissue (MALT)
H/o endoscopic resxn of early gastric CA
Uninvestigated dyspepsia if < 60 (without alarm features)
Chronic NSAIDs
Unexplained iron deficiency anemia
ITP
/

Question 18

Alarm features for H. Pylori?

Answer 18

bleeding
anemia
early satiety
unexplained weight loss
progressive dysphagia
recurrent vomiting
family h/o GI CA
\

Question 19

Mallory-Weiss tears are what?

Answer 19

mucosal & possibly submucosal lacerations from sudden increase in pressure in cardia & lower esophagus from vomiting

Question 20

Mallory-Weiss tears
how to stop bleeding?
tears are usually how long and where?

Answer 20

usually ceases spontaneously
1.5-2 cm; @ GE junction or proximal stomach

Question 21

Dieulafoy’s lesions
what are they?
Where are they typically located?

Answer 21

visible vessel protruding from small mucosal defect no ulceration
in lesser curvature

Question 22

Benign GI Neoplasms

Answer 22

GISTs
Carcinoid
lipomas

Question 23

Malignant GI Neoplasms

Answer 23

adenoca of esophagus
stomach
duodenum
SCCA of esophagus
gastric or duodenal lymphomas

Question 24

H. Pylori Treatment Is there a PCN allergy? N Previous Macrolide exposure for any reason? N What is the recommended treatment?

Answer 24

Bismuth quadruple CONCOMITANT Clarithromycin triple with amoxicillin

Question 25

H. Pylori Treatment Is there a PCN allergy? N Previous Macrolide exposure for any reason? Y What is the recommended treatment?

Answer 25

Bismuth quadruple Levofloxacin triple Levofloxacin sequential

Question 26

H. Pylori Treatment Is there a PCN allergy? Y Previous Macrolide exposure for any reason? N What is the recommended treatment?

Answer 26

Clarithromycin triple with metronidazole Bismuth quadruple

Question 27

H. Pylori Treatment Is there a PCN allergy? Y Previous Macrolide exposure for any reason? Y What is the recommended treatment?

Answer 27

Bismuth quadruple

Question 28

Hx found in varices

Answer 28

Symptoms of liver dz family h/o hereditary liver dz (Wilson Dz) Lifestyle (ETOH, drugs) PMH - jaundice, prior blood transfusions

Question 29

Exam for varicies

Answer 29

signs of bleeding dyspnea jaundice telangiectasia palmar erhythema if cirrhosis ascites distended abd wall veins

Question 30

Risk factors for Stress-Related Mucosal Dz

Answer 30

recent major surgery major trauma severe burns TBI MSOF MV>48hrs coagulopathy (plt ct < 50, INR > 1.5, PTT > 2x NL) /

Question 31

GI prophylaxis Level I recs All patients with? Level II recs ICU patients with what? Level III recs Injury severity score > what? and what med?

Answer 31

MV, coagulopathy, TBI, major burn multi-trauma, sepsis, acute renal failure 15; high dose steroids (>250mg hydrocortisone/day)

Question 32

GI Prophylaxis preferred agents Level I recs: no difference b/t what meds? shouldn't use what? Level II recs: what meds shouldn't be used in dialysis patients? Level III recs: what alone may be insufficient prophylaxis?

Answer 32

H2RAs, cytoprotectives & PPI; Antacids aluminum containing meds enteral nutrtion

Question 33

GI prophylaxis Duration of therapy Level I? Level II? Level III?

Answer 33

none duration of MV or ICU stay until able to tolerate enteral nutrition

Question 34

Treatment for Stress-Related Mucosal DZ Upper GI bleed?

Answer 34

Endoscopy as in PUD Surgery for those with uncontrolled hemorrhage; usually vagotomy, oversew, or subtotal/total gastrectomy (rare)

Question 35

Lower GI Bleeding from where?

Answer 35

from source distal to ligament of Treitz

Question 36

Risk factors for Lower GI bleeding?

Answer 36

Antiplatelets NSAIDs P2Y12 inhibitors

Question 37

Diverticular Dz most common cause of lower GI bleed with up to what % of cases? More often in who? affecting up to 2/3 of those > what? ~3-15% of those with diverticulosis experience what? patients experience painless what? Usually ceases how? but can recur in up to what % of cases?

Answer 37

40% elderly; 80 yrs bleeding hematochezia 40%

Question 38

Ischemic Colitis/other Colitis responsible for what % of LGIBs? sudden decrease in what? typical areas of involvement include what areas? Patients experience what symptoms? usually resolves how? Common cause of LGIB in ICU d/t what? On endoscopy usually appears as what? severe bleeding from infectious colitis, XRT colitis, and inflammatory bowel dz is what?

Answer 38

19% mesenteric flow; transient and reversible watershed areas: splenic flexure, rectosigmoid junction, R colon sudden abd pain, hematochezia w/n 24 hrs spontaneously w/ support, rarely requires surgery hemorrhagic nodules, cyanotic or necrotic mucosa with heomrrhagic ulcerations, or abrupt transition b/t injured & normal mucosa rare

Question 39

Angiodysplasia Rates of occurrence as source of LGIB vary widely up to what %? Primarily in what population? bleeding usually has what characteristics? On endoscopy lesions are what?

Answer 39

37% elderly brisk, painless, difficult to distinguish from diverticular bleed flat & red with vessels extending from central feeding vessel, usually R colon

Question 40

Small bowel sources of LGIBs

Answer 40

angiodysplasia lymphoma SB ulcers Crohn's dz

Question 41

Other sources of LGIBs

Answer 41

Hemorrhoids CA Post polypectomy Ulcers XRT

Question 42

Diagnostic Evaluations include?

Answer 42

Colonoscopy CT angio Surgery

Question 43

Anticoagulation Guidance in GI Bleed

Answer 43

DC NSAIDs (in diverticular bleed) DC ASA if used for primary CV prevention (Diverticular bleed) Continue ASA if prior CV dz (diverticular bleed) resume anticoagulants after cessation of bleeding