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Upper GI Bleeding Flashcards

1
Q

Upper GI bleeding commonly presents with…

A
  • Hematemesis

- Melena

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2
Q

Upper and lower GI bleeding defined based on their location relative to…

A

Ligament of Treitz

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3
Q

Obscure bleeding

A

Hemorrhage that persists or recurs after negative endoscopy (source not apparent)

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4
Q

Occult bleeding

A

Hidden bleeding found accidentally

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5
Q

Shock

A

Organs and tissues of the body not receiving adequate blood flow allowing for buildup of waste products

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6
Q

Hypovolemic shock

A

Hemorrhagic

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7
Q

Stage I (compensated) of shock

A
  • Tachycardia
  • Vasospasm
  • Pt has few symptoms
  • Tx can halt
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8
Q

Stage II shock

A
  • Agitation, confusion, disorientation
  • Myocardial ischemia (w or w/o chest pain)
  • Decreased urine output
  • Tx reverse
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9
Q

Stage III shock

A
  • Heart fails
  • Kidneys fail
  • Circulatory collapse
  • End-organ damage
  • Death
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10
Q

Generalities of treating shock

A
  • Rapidly diagnose the state of shock
  • Diagnose the underlying condition
  • Quickly intervene to halt the underlying condition
  • Treat the effects of shock
  • Support vital functions
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11
Q

Initial assessment

A
  • ABCs (airway, breathing, circulation)
  • Stable/unstable?
  • Resuscitation
  • Oxygen
  • Trendelenburg position
  • IV
  • Blood transfusion
  • Urgent surgical consultation
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12
Q

BUN:Creatinine ratio suggestive of upper GI bleed

A

> 36:1

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13
Q

Signs and symptoms of shock

A
  • Systolic BP <100 mmHg
  • Pulse >100/min
  • Cool, clammy skin
  • Prolonged capillary refill
  • Changing mentation
  • Complaints of syncope/near-syncope
  • Decreased urine output
  • Narrowed pulse pressure
  • Hypotension
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14
Q

Positive orthostatics estimate how much loss of TBV

A

15-20%

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15
Q

Resting hypotension indicates how much loss of TBV

A

30-40%

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16
Q

ATLS guidelines for assessing shock patients

A

Any patient who is cool and tachycardic is in shock until proven otherwise

17
Q

Risk factors for morbidity and mortality in acute GI hemorrhage

A
  • Age >60 yr
  • Comorbid disease (renal failure, liver disease, respiratory insufficiency, cardiac disease)
  • magnitude of hemorrhage
  • Persistent or recurrent hemorrhage
  • Inpatient at time of bleed
  • Severe coagulopathy
  • Need for surgery
18
Q

Proton pump inhibitors

A
  • Start empirically prior to endoscopy
  • High dose IV (pantoprazole, lansoprazole, esomeprazole)
  • Can accelerate resolution of recent UGIB
  • Can decrease length of hospital stay
  • Significant reduction in risk of re-bleeding
  • Improvement in mortality
19
Q

PUD

A
  • Duodenal or gastric

- Imbalance between protective mucosa and acid/pepsin

20
Q

4 major risk factors for PUD

A
  • H. pylori infection
  • Use of NSAIDs
  • Physiologic stress
  • Excess gastric acid
21
Q

Clinical features of PUD

A
  • Epigastric pain
  • Gastric ulcers (pain 5-15 minutes after eating, relieved by fasting, high risk of malignancy)
  • Duodenal ulcers (pain 2-3 hours after eating, pain relieved temporarily by food, pain may wake at night, low risk of malignancy)
  • Epigastric tenderness
22
Q

Therapy for PUD

A
  • EGD
  • H2Blockers
  • PPIs
  • Sucralfate
23
Q

Treatment of H. pylori

A
  • Helidac therapy

- Prevpac therapy

24
Q

Aspirin and NSAIDs and GI bleed

A
  • Cause of both UGIB and LGIB
  • NSAIDs and ASA inhibit cyclooxygenase mediated PGD synthesis so impairs mucosal protection
  • High risk of bleeding in elderly w/o warning symptoms
25
Other causes of PUD
- Stress ulcers - Gastric acid - Esophagitis - Dieulafoy's lesion - Malignancy
26
Dieulafoy lesions
Large submucosal a. protruding through the mucosa (w/i fundus) -More common in males
27
Mallory-Weiss tears
- Longitudinal tear near GE junction - Due to intense retching/vomiting - Tx supportive
28
Cameron lesions/ulcers
- Linear erosion/ulceration in the proximal stomach located at the end of a large hiatal hernia at the diaphragmatic pinch. - Thought to be due to mechanical trauma and local ischemia. - May present with overt bleeding. - Usually present as occult bleeding - Common cause of obscure bleeding. - Treatment is iron supplements and oral PPI. - Occasionally surgical repair of the hiatal hernia needed.
29
Esophageal varices
-Due to portal hypertension -High risk of mortality -High risk of rebleed -Medical management: >>Somatostatin >>Octreotide -Endoscopic management: >>Sclerotherapy >>Band ligation -Other: >>Sengstaken-Blakemore tube >>TIPS procedure >>Non-selective beta blocker >>PPI
30
Class I hypovolemic shock
- Up to 750 mL blood loss (up to 15%) - pulse <100 - BP normal - Pulse pressure normal or increased - RR 14-20 - Urine output >30 mL/hr - Mental status: slightly anxious - Crystalloid fluid replacement
31
Class II hypovolemic shock
- 750-1000 mL lost (15-30%) - pulse <100 - BP normal - Pulse pressure decreased - RR 20-30 - Urine output 20-30 mL/hr - Mental status: mildly anxious - Crystalloid fluid replacement
32
Class III hypovolemic shock
- 1500-2000 mL lost (30-40%) - pulse >120 - BP decreased - Pulse pressure decreased - RR 30-40 - Urine output 5-15 mL/hr - Mental status: anxious, confused - Crystalloid and blood replacement
33
CLass IV hypovolemic shock
- 2000 mL lost (>40%) - pulse >140 - BP decreased - Pulse pressure decreased - RR >35 - Urine output negligible - Mental status: confused, lethargic - Crystalloid and blood replacement
34
Blatchford score
- Often used for initial assessment | - any score >1 = admission
35
Rockall score
- Often used for risk assessment for re-bleeding or complications - 0-2 = low risk - >8 = poor prognosis
36
Stress ulcers
- Multiple superficial erosions - High risk in ICU pt - Cushing's ulcers (associated with head injury - Curling's ulcers (associated with burns)
37
Zollinger-Ellison syndrome
Increased production of gastric acid leading to destruction of natural mucosa

GI (8 decks)

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