Upper GI Bleeding Flashcards Preview

ACNP III - Exam 2 > Upper GI Bleeding > Flashcards

Flashcards in Upper GI Bleeding Deck (12):
1

What are the 3 different types of GI bleeding?

  1. Overt – acute bleeding, presenting with either hematemesis, ‘coffee ground’ emesis, melena or hematochezia; angiography and radionuclide imaging (tagged RBC scan performed in nuclear medicine) are most widely utilized for acute overt bleeding
  2. Occult – chronic bleeding; resulting from microscopic hemorrhage; may present with Hemoccult + stools with or without iron deficiency anemia
  3. Obscure – initially presenting with a + fecal occult blood test (FOBT) and/or iron deficiency anemia when there is no evidence of visible blood loss; recurrent bleeding without identification of a source even after upper endoscopy and colonoscopy; can be either overt or occult; capsule endoscopy and deep enteroscopy are utilized in the diagnosis of obscure bleeding originating from the small bowel

2

What classifies an upper GI bleed?

Refers to intraluminal blood loss from any location between the upper esophagus to the duodenum at the ligament of Treitz

3

What are common causes of upper GI bleeds?

  1. Gastric and/or duodenal ulcers
  2. Severe or erosive gastritis/duodenitis
  3. Severe or erosive esophagitis
  4. Esophagogastric varices
  5. Portal hypertensive gastropathy
  6. Angiodysplasia (vascular ectasia)
  7. Mallory-Weiss syndrome
  8. Mass lesions (polyps/cancers)
  9. Dieulafoy’s Lesions – vascular malformation of the submucosal artery located in the proximal stomach abnormally close to the mucosa that erodes the epithelium and can result in massive UGIB

4

How can PUD cause upper GI bleeding?

There are 4 major risk factors for bleeding peptic ulcers:

  1. H.pylori infection - spiral bacterium that infects superficial gastric mucosa and disrupts mucous layers making it more susceptible to acid damage; h.pylori infection is associated in most patients with duodenal ulcers that are NOT related to NSAID use

  2. NSAID’s - including low-dose aspirin

  3. Physiologic stress

  4. Excess gastric acid - control of gastric acidity is considered an ESSENTIAL therapeutic maneuver in patients with active UGIB

5

How can Esophagitis lead to upper GI bleeding?

1. Gastroesophageal reflux disease (GERD)

2. Medication use: NSAIDs, oral bisphosphonates

3. Infections (Candida, herpes simplex virus

6

How does Gastritis/Duodenitis lead to upper GI bleeding?

Predominantly inflammatory processes; rarely leads to significant UGIB; commonly identified at time of endoscopy; risk factors include:

1. risk factors for peptic ulcer disease above, plus

2. excessive alcohol consumption

3. radiation injury

4. obesity surgery

5. chronic bile reflux

7

How does Portal Hypertensive Gastropathy lead to upper GI bleeding?

While most patients with portal hypertension have cirrhosis and esophageal varices; portal hypertension DOES EXIST WITHOUT CIRRHOSIS and is termed non-cirrhotic portal hypertension; causes of non-cirrhotic portal hypertension include:

1. portal vein thrombosis

2. schistosomiasis

3. idiopathic non-cirrhotic portal hypertension

4. thrombosis of mesenteric vessels

8

What are the clinical manifestations associated with upper GI bleeding?

  • Abdominal pain/discomfort
  • Hematemesis- either bright red blood or coffee ground emesis
  • Melena
  • Hypovolemic shock with acute blood loss
  • Orthostatic changes – noted with a 20% or more loss of blood volume
  • Skin pallor
  • Spider angiomas
  • NGT aspirate: bright red blood indicates active bleeding and is associated with a higher mortality than melena alone

9

What labs/diagnostic tests are used to diagnose an upper GI bleed?

  • Type and Cross for at least 4 unit PRBCs
  • CBC, Coagulation panel, electrolytes, BUN/creatinine, liver enzymes
  • EKG
  • Endoscopy – both diagnostic and therapeutic; should be considered in asymptomatic patients who present with a high suspicion for cirrhosis and esophageal varices who have a + fecal occult blood test
  • Capsule endoscopy – small camera ingested to examine entire length of small bowel; provides direct visualization of mucosa; diagnostic only
  • Nuclear medicine bleeding scan (Tagged RBC scan) and/or Angiography

10

How do you manage a patient with an upper GI bleed?

1. Primary survey: Airway, Breathing, Circulation

2. Endotracheal intubation if required

3. STAT GI and Surgery consult

4. If acute significant blood loss, place 2 large bore IV lines or a central line for fluid resuscitation

5. Blood transfusion if warranted – Keep Hematocrit above 30%

  • Patients with coagulopathies (elevated INR); 1-2 units FFP and 2.5-10 mg vitamin K IM or IV
  • Low platelet count- transfuse platelets if actively bleeding

6. NGT placement – tap water gastric lavage

  • If aspirate does not clear after 2-3 liters, continued active bleeding is assumed
  • More urgent resuscitation and endoscopic interventions are indicated

7. Endoscopy – consider in all patients with UGIB

  • Emergently indicated with active UGIB after stabilization
  • Active, self-limited bleeds – perform within 24 hours, unless bleeding re-occurs
  • Chronic blood loss – may undergo elective endoscopy
  • Treatment options with EGD include:
    • Thermal coagulation, i.e. cauterization
    • Injection therapy with epinephrine or sclerosant
    • Band ligation

8. Balloon Tamponade (i.e. Blakemore tube) if EGD fails to stop bleeding

11

What medications are used to manage patients with upper GI bleeding?

IV proton pump inhibitors- for acute bleeds

  • Pantoprazole (Protonix) 80mg IV bolus, followed by continuous infusion OR
  • Octreotide IV continuous infusion

Pro-kinetic agent

  • Single dose prior to endoscopy promotes gastric emptying and clearance of blood, clots and food
  • Metoclopramide (Reglan) IV

Prophylactic Antibiotics

 

  • Ciprofloxacin IV OR Ceftriaxone 1 gm/day IV
    • 7-day maximum course
    • Shown to significantly reduce bacterial infections
    • May reduce mortality, re-bleeding events and hospitalization length

 

12

When is surgery indicated for upper GI bleeding?

  • Severe bleeding or re-bleeding in which 2 endoscopic treatments have failed;
  • Massive exsanguination in which resuscitative efforts have failed
  • After more than 6-8 units of PRBCs were required within first 24-hour period
  • Slow continuous bleed lasting longer than 48 hours
  • Non-surgical patients, consult interventional radiologist for arteriogram/embolization
  • Upper GI barium studies are contraindicated in cases of UGIB