Flashcards in Tutorial 3: GI bleed, cirrhosis, acute abdo pain Deck (57)
What is hematemesis?
vomiting of red blood and indicates upper GI bleeding
Usually from a peptic ulcer, vascular lesion, or varix.
What is coffee-ground emesis?
vomiting of dark brown, granular material that resembles coffee grounds.
It results from upper GI bleeding that has slowed or stopped, with conversion of red hemoglobin to brown hematin by gastric acid.
What is hematochezia?
passage of gross blood from the rectum and usually indicates lower GI bleeding but may result from vigorous upper GI bleeding with rapid transit of blood through the intestines.
What is melena?
black, tarry stool and typically indicates upper GI bleeding, but bleeding from a source in the small bowel or right colon may also be the cause.
How much blood is required to cause melena?
About 100 to 200 mL of blood in the upper GI tract i
What else can cause black stool? (not bleeding)
iron, bismuth, or various foods
How is chronic occult bleeding diagnosed?
can occur from anywhere in the GI tract and is detectable by chemical testing of a stool specimen.
Name common causes of upper GI tract bleeds
Duodenal ulcer (20–30%)
Gastric or duodenal erosions (20–30%)
Gastric ulcer (10–20%)
Mallory-Weiss tear (5–10%)
Erosive esophagitis (5–10%)
Arteriovenous malformations (< 5%)
Gastrointestinal stromal tumors
Name common causes of lower GI tract bleeds
Angiodysplasia (vascular ectasia)
Colitis: Radiation, ischemic, infectious
Inflammatory bowel disease: Ulcerative proctitis/colitis, Crohn disease
Name causes of small bowel lesions
Where is the division drawn between upper GI and lower GI?
above the ligament of Treitz
What drugs are associated with BI gleed?
anticoagulants (eg, heparin, warfarin)
those affecting platelet function (eg, aspirin and certain other nonsteroidal anti-inflammatory drugs [NSAIDs], clopidogrel, selective serotonin reuptake inhibitors [SSRIs])
and those affecting mucosal defenses (eg, NSAIDs).
What comorbidities directly make GI bleeds more likely?
chronic liver disease (eg, alcoholic liver disease, chronic hepatitis)
hereditary coagulation disorders
What makes taking a history of GI bleed difficult, and how should you get around it?
even small amounts (5 to 10 mL) of blood turn water in a toilet bowl an opaque red, and modest amounts of vomited blood appear huge to an anxious patient.
However, most can distinguish between blood streaks, a few teaspoons, and clots.
What should you ask a pt about their hematemesis?
whether blood was passed with initial vomiting or only after an initial (or several) nonbloody emesis
specific questions to distinguish between hematemesis and hemoptysis (pts confuse them)
What should you ask a pt about their rectal bleeding?
whether pure blood was passed; whether it was mixed with stool, pus, or mucus; or whether blood simply coated the stool or toilet paper
What history should you ask about for a pt with bloody diarrhea?
travel or other possible exposure to GI pathogens.
What should you make sure to include in your ROS for GI bleed?
easy bleeding or bruising
previous colonoscopy or endoscopy results
symptoms of anemia (eg, weakness, easy fatigability, dizziness).
What PMHX should be elicited for GI bleeds?
previous GI bleeding (diagnosed or undiagnosed); known inflammatory bowel disease, bleeding diatheses, and liver disease; and use of any drugs that increase the likelihood of bleeding or chronic liver disease (eg, alcohol).
What does the physical exam focus on for GI bleed?
vital signs and other indicators of shock or hypovolemia
What other physical exam findings should you look for?
External stigmata of bleeding disorders (eg, petechiae, ecchymoses)
Signs of chronic liver disease (eg, spider angiomas, ascites, palmar erythema)
Signs of portal hypertension (eg, splenomegaly, dilated abdominal wall veins).
What physical exam component is necessary?
DRE: stool color, masses, fissures
Consider anoscopy to Dx hemorrhoids
Occult blood test
List red flag signs for hypovolemia or hemorrhagic shock
Suspicion of bleed + ... Epigastric abdominal discomfort relieved by food or antacids suggests...
Peptic ulcer disease
(However, many pt with bleeding ulcers don't have pain)
Suspicion of bleed + ... A history of cirrhosis or chronic hepatitis
Suspicion of bleed + dysphagia
Suspicion of bleed +
Vomiting and retching before the onset of bleeding
Mallory weiss tear
(although about 50% of patients with Mallory-Weiss tears do not have this history.)
Suspicion of bleed + Hx of bleeding (eg, purpura, ecchymosis, hematuria)
(eg, hemophilia, hepatic failure).
Bloody diarrhea, fever, and abdominal pain suggest
inflammatory bowel disease (eg, ulcerative colitis, Crohn disease)
infectious colitis (eg, Shigella, Salmonella, Campylobacter, amebiasis)