GI Bleeding Flashcards Preview

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Flashcards in GI Bleeding Deck (42)
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1
Q
Hematemesis
A
bright red blood in vomit, or coffee ground type material
2
Q
Melena
A
black, tar like stool
3
Q
Hematochezia
A
BRBPR (bright red blood per rectum), usually lower, but if
massive upper GIB, can have this
4
Q
Esophagus spinal level
A
T2-T8
5
Q
Spinal level for Upper GI Tract
(Stomach, Liver, Gallbladder, Spleen, Portions of Pancreas and Duodendum)
A
T5-T9, Greater Splanchnic Nerve Celiac Ganglion
6
Q
Spinal level for Middle GI Tract
(Portions of Pancreas and Duodenum, Jejunum, Ileum, Ascending Colon, and 2/3 of Transverse Colon)
A
T10-T11, Lesser Splanchnic Nerve Superior Mesenteric Ganglion
7
Q
Lower GI Tract
(Distal 1/3 of Transverse Colon, Descending Colon and Sigmoid Colon, Rectum)
A
T12-L2, Least Splanchnic Verse Inferior Mesenteric Ganglion
8
Q
Acute upper GI bleed can be from
A
-Peptic Ulcer Disease (H pylori)

-Portal Hypertension: 10-20% of cases; can be massive due to esophageal or gastric varices; pressures in portal system, draining into liver, esophageal varices are very risky if they start bleeding

-Mallory Weiss tear
9
Q
Initial step for acute GI bleed
A
-NG tube? Gastric Lavage?
-Rectal?
-Hemodynamic Stabilization
--BP Systolic 100 response to acute
--blood loss, first vital sign of change
-HCT takes 24-72 hours to equilibrate
-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?
-Give bolus of IV saline until you can see what hemoglobin levels are
10
Q
Goal of hemoglobin?
A
New guidelines:
-7 is threshold now, unless cardiac history then consider goal of >9 (if having MI; want to increase oxygenation to cardiac muscle)
-Platelets > 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
11
Q
Uremia? End Stage Renal Disease patient? Consider _________
A
DDAVP (desmopressin acetate, synthetic ADH)

-in pts with uremia, platelets are there but don’t stick together well bc of uremia, DDAVP helps promote platelet adhesion, makes them sticky again
12
Q
History items to consider during acute upper GI bleed
A
-Aspirin? Cant reverse- takes 10-14 days to get our of your system (Clopridogrel and ASA- platelets are irreversibly inhibited)
-NSAIDS? Cant reverse
-NOAC? Novel oral anticoagulation
-Cirrhosis? Think esophageal varices

-WHEN WAS THE LAST DOSE TAKEN?
13
Q
Role of upper endoscopy in acute upper GI bleed
A
-Stabilize patient first hemodynamically
-Cautery, injection, endoclips
-Banding varices
-Bleeding ulcer or vessel: vessel they can clip, clips fall off on their own
-Put rubber bands on esophageal varices to prevent them from bleeding/rupturing
14
Q
Pharmacologic therapy for acute upper GI bleed
A
-IV PPI (bolus then drip for 72 hours)
-Consider PO PPI if low risk features
-Octreotide: gastric varices in liver patients, prevent them from bleeding worse if they have a small bleed- given IV
Patient’s with esophageal or gastric varices, liver disease, portal HTN; Reduces splanchnic blood flow and portal blood pressures
15
Q
Long term side effects with PPI use
A
-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
16
Q
Acute lower GI bleed
A
-Hematochezia
-10% due to upper source
-Lower definition: below ligament of Treitz
17
Q
Causes of acute lower GI bleed
A
-Diverticulosis (can erode a blood vessel and bleed; acute, painless, large volume possible)
-Angioectasia: more common in CKD/ESRD patients
-Neoplasms
-IBD
-Anorectal disease (hemorrhoids, fissures)
-Ischemic Colitis (older pt, nonocclusive ischemia, usually self limited)
-Radiation induced proctitis (can irritate mucosa)
18
Q
Test for acute lower GI bleed
A
-Exclude upper GIB (NGT, lavage)
-Rectal Exam
-Colonoscopy or sigmoidoscopy
(Prep with GoLYTELY 3.8L)
-NM PRBC Scan (if positive, next step is angiography; Localization is poor, and
19
Q
Crohn's vs UC: Site of origin
A
C- terminal ileum
UC- rectum
20
Q
Crohn's vs UC: Pattern of progression
A
C- Skip lesions/irregular
UC- proximally contiguous
21
Q
Crohn's vs UC: Thickness of inflammation
A
C- transmural (across wall)
UC- submucosa or mucosa
22
Q
Crohn's vs UC: Symptoms
A
C- crampy abdominal pain
UC- bloody diarrhea
23
Q
Crohn's vs UC: Complications
A
C- fistulas, abscess, obstruction
UC- hemorrhage, toxic megacolon
24
Q
Crohn's vs UC: Radiographic findings
A
C- string sign on brain X-ray
UC- lead pipe colon on barium X-ray
25
Q
Crohn's vs UC: Risk of colon cancer
A
C- slight increase
UC- marked increase
26
Q
Crohn's vs UC: Surgery
A
C- for complications such as stricture
UC- curative (take out whole colon to rule out cancer, use colostomy bag)
27
Q
Transfusion in acute upper GI bleed
A
-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
28
Q
New anticoagulants in GI bleed
A
Pradaxa – dabigatran
Xarelto – rivaroxaban
Eliquis - apixaban

-metabolized in kidney, warfarin is in liver
-Expensive, don’t have to get INR checked regularly
Coumadin, Warfarin take 72 hours to become activated and work

-These meds start working within hours- advantage if you are already bleeding- within 24-48 hrs they are out of your system
-Direct factor 10a inhibitors (3 of them)
-Block thrombin (1 of them)
29
Q
see slide 26
A
see slide 26
30
Q
New anticoagulant risks
A
-Lower risk of hemorrhagic stroke brain bleed
-Higher risk of GI bleed
31
Q
When to resume Warfarin after GI bleed
A
-GIB defined by HGB drop by 2 grams, visible bleeding, or positive endoscopic evaluation

-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.
32
Q
Put older people on anti platelet therapy to prevent
A
them from bleeding (on steroids, NSAIDS, put them on pentoprazol to prevent a bleeding ulcer, even with the risk of C diff)
33
Q
INR goal of 2-2.5 is recommended for
A
-Combination of aspirin and heparin/LMWH/warfarin or clopidogrel
34
Q
Use of low dose aspirin for cardiovascular prophylaxis associated with
A
2-4 fold increase in upper gastrointestinal events

-AHA recommends low dose aspirin in patient with 10 year cardiovascular risk > or = 10%
-Full 325 ASA for prevention- very high bleeding risk- don’t need to use this
81 mg does just as good and has LOWER bleeding risk
35
Q
Gastric ulcer indication
A
Greater pain with meals
36
Q
Duodenal ulcer indication
A
Decreased pain with meals
37
Q
Ischemic colitis indication
A
post-prandial abdominal pain, older patient, hematochezia
38
Q
H2 blockers
A
famotidine, ranitidine – Block H2 receptors of parietal cells
39
Q
PPIs
A
omeprazole, pantoprazole

-Inhibit H+/K+ ATPase in parietal cells
-Low magnesium levels possible with long term use, higher risk of C diff
40
Q
Magnesium
A
Makes you go, take for constipation
41
Q
Aluminium
A
minimum amount of feces, take for diarrhea
42
Q
Osmotic laxatives
A
PEG, lactulose