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SOM 309 (313): GASTROINTERSTINAL DISEASES > WEEK 4: GI Bleeding > Flashcards

WEEK 4: GI Bleeding Flashcards

1
Q

Q: What does GIT stand for?

Q: What organs are included in the Gastrointestinal Tract (GIT)?

Q: Where does the GIT extend from and to?

A

A: GIT stands for Gastrointestinal Tract.

A: The GIT includes the stomach, small intestine, and large intestine.

A: The GIT extends from the Z-line at the esophago-gastric junction to the dentate line at the anorectum.

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2
Q

Q: How does the GIT differ from the Alimentary Tract?

A

A: The GIT does not include organs such as the esophagus, liver, biliary tree, and pancreas, whereas the Alimentary Tract does.

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3
Q

Q: What are other names for Upper GI Endoscopy?

Q: What is the purpose of an OGD or EGD procedure?

A

A: Upper GI Endoscopy is also referred to as OGD or EGD, which stands for (O)Esophago-Gastro-Duodenoscopy.

A: The purpose of an OGD or EGD procedure is to visualize the esophagus, stomach, and duodenum as distally as possible, typically reaching the second or third part of the duodenum.

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4
Q

Q: What does UGIB stand for?

Q: What does NVGIB stand for?

Q: What does VGIB stand for?

A

A: UGIB stands for Upper Gastrointestinal Bleed.

A: NVGIB stands for Non-Variceal GIB. Refers to bleeding in the gastrointestinal tract that is not caused by varices, which are SUBMUCOUSAL VEINS usually found in the esophagus or stomach.

A: VGIB stands for Variceal GIB.

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5
Q

Q: What does LGIB stand for?

Q: What is a Cryptic GIB?

A

A: LGIB stands for Lower Gastrointestinal Bleed.

A: Cryptic GIB is a type of bleed that cannot be readily localized and often arises in the distal duodenum, jejunum, or ileum.

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6
Q

Rare sources of blood in the GI Tract but not arising from the GIT per se
Q: What is Hemobilia?

A

A: Hemobilia is a condition where blood from the liver enters the duodenum via the Papilla of Vater.

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7
Q

Rare sources of blood in the GI Tract but not arising from the GIT per se
Q: What is Hemosuccus pancreaticus?

A

A: Hemosuccus pancreaticus is a condition where blood from the pancreas enters the duodenum via the Papilla of Vater.

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8
Q

Rare sources of blood in the GI Tract but not arising from the GIT per se
Q: What is an Aortoenteric fistula?

A

A: An Aortoenteric fistula is a condition that is seen after a prosthetic graft replacement for an abdominal aortic aneurysm (AAA). It involves an abnormal connection between the aorta and the intestine, resulting in bleeding.

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9
Q

Discuss some Causes of GI Bleeds in Children

A
  1. Intussusception: Intussusception is a cause of GI bleeding in children, but it is not covered in the provided information.
  2. Meckel’s Diverticulum: Meckel’s diverticulum is a common cause of GI bleeding in children. It is the most common congenital abnormality of the small intestine and occurs due to an incomplete obliteration of the vitelline duct. Meckel’s diverticulum may contain cells from both the stomach and pancreas, which can secrete acid and cause ulcers and bleeding
    .
  3. Anal Fissure: Infants with blood in the diaper may have blood from an anal fissure. Anal fissures are small tears in the lining of the anus and can cause bleeding
    .
  4. Benign Polyps: Benign polyps, particularly the juvenile type, can cause GI bleeding in children. These polyps are usually located throughout the colon and are benign hamartomas that may autoamputate and require no treatment. However, bleeding polyps can be excised during colonoscopy
    .
  5. Bleeding from Ileal Ulcer in Typhoid Fever: In parts of sub-Saharan Africa, bleeding from an ileal ulcer caused by typhoid fever can occur and may be massive and lethal.
  6. Esoteric and Rare Causes: There are several esoteric and rare causes of GI bleeding in children, including:
    *Familial Adenomatous Polyposis and Peutz-Jeghers Polyps
    *Inflammatory Bowel Disease
    *Necrotizing Enterocolitis (NEC)
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10
Q

Epidemiology of Upper GI Bleeds

Q: What is the mortality rate of Acute Upper GI Bleeds (UGIB) despite advances in critical care monitoring and support?

Q: What percentage of UGIB cases experience spontaneous cessation of bleeding?

A

A: The mortality rate of Acute UGIB is 4%-14%.

A: Approximately 85% of UGIB cases experience spontaneous cessation of bleeding.

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11
Q

Q: How many cases of UGIB are reported in the UK per year?

Q: What is the most common cause of UGIB cases?

A

A: UGIB in the UK ranges between 84-172 cases per 100,000 per year, causing 50-70,000 hospital admissions annually.

A: The majority of UGIB cases are caused by Peptic Ulcer Disease (PUD).

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12
Q

Outline Etiology of UGIB - UK

A

PUD (~26%)
Gastritis (16%)
Esophageal Varices (8%)
Mallory Weiss tear (3%)
Duodenitis (9%)
Esophagitis (17%)

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13
Q

What causes the mortality rate which is much higher than any other cause of UGIB?

A

The mortality rate for variceal bleeding is 30-50%, which is much higher than any other cause of UGIB

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14
Q

Q: What percentage of GI bleeds are classified as Upper GI Bleeds (UGIB)?

Q: Where is the location of bleeding in UGIB?

Q: What are the common presenting symptoms of UGIB?

A

A: Approximately 80% of GI bleeds are classified as Upper GI Bleeds.

A: UGIB occurs proximal to the ligament of Treitz at the duodenojejunal flexure.

A: The common presenting symptoms of UGIB include hematemesis (vomiting of blood) and melena (black, tarry stool).

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15
Q

Q: What percentage of GI bleeds are classified as Lower GI Bleeds (LGIB)?

Q: Where is the location of bleeding in LGIB?

Q: What are the common presenting symptoms of LGIB?

A

A: Approximately 20% of GI bleeds are classified as Lower GI Bleeds.

A: LGIB occurs distal to the ligament of Treitz.

A: The common presenting symptoms of LGIB include rectal bleeding or hematochezia (passage of bright red blood or clots per rectum)

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16
Q

Q: What is the difference between bright red blood per rectum and melena?

A

A: Bright red blood per rectum refers to the passage of fresh red blood from the rectum, while melena refers to black, tarry stool that occurs when blood is exposed to acid or remains in the small intestine for a prolonged period of time

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17
Q

Q: What is the significance of bright red blood per rectum in terms of location of bleeding?

A

A: Bright red blood per rectum suggests a lesion in the rectum or anus. However, it can also occur with pathology higher in the GI tract if the transit of blood through the gastrointestinal tract is rapid.

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18
Q

Discuss Etiologies of UGIB

A
  1. Peptic ulceration (35-50%)
    Duodenal: mostly H. Pylori related
    Gastric: NSAIDS, steroids, H. Pylori
    Marginal ulcer after a gastrojejunostomy
  2. Reflux esophagitis (20-30%)
  3. Gastritis (10-20%)
    Alcohol, NSAIDS, Steroids
  4. Varices: (5-12%)
    Esophageal
    Gastric
  5. Mallory-Weiss tear (2-5%): Tear in the lining of the esophagus
  6. Neoplasm (2-5%)
  7. Angiodysplasia (<1%)
  8. Aortic-enteric fistula
  9. Bleeding disorders
  10. Dieulafoy’s lesion (SAM = submucosal arteriolar malformation)
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19
Q

Discuss Etiology of Lower GI Bleeds.

A
  1. Diverticular disease (> 50% of cases) diverticulosis, not “itis”.
  2. Neoplasm: colon, rectum, anus, small bowel
  3. Inflammatory Bowel Disease (IBD): Crohn’s disease, ulcerative colitis
  4. Colitis non IBD: infectious, ischemic, post irradiation, pseudomembranous,
  5. Angiodysplasia; arteriovenous malformation
  6. Intussusception
  7. Polyps: colonic polyps, Familial adenomatous polyposis (FAP), Peutz-Jeghers syndrome
  8. Benign anorectal disease: hemorrhoids, anal fissure
  9. Bleeding diathesis
  10. Iatrogenic: Post biopsy or polypectomy
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20
Q

Q: What is the spontaneous cessation rate of lower GI bleeding?

Q: What percentage of patients with severe hematochezia have an upper GI source of bleeding?

A

A: Lower GI bleeding stops spontaneously in approximately 80-85% of patients.

A: Approximately 15% of patients with severe hematochezia have a source of bleeding in the upper GI tract.

NOTE: Hematochezia is the passage of fresh, bright red blood in the stool, usually from the lower gastrointestinal tract.

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21
Q

Q: What is the recommended approach for patients with hematochezia and hemodynamic instability suspected to be due to an upper GI bleed?

Q: How can an elevated BUN-creatinine ratio be suggestive of an upper GI bleed?

A

A: In cases where a patient presents with hematochezia and hemodynamic instability, which is likely due to an upper GI bleed, urgent upper endoscopy is recommended after resuscitation.

A: An elevated BUN-creatinine ratio (>30:1) suggests an upper GI bleed and has a likelihood ratio of 7.5 for an upper GI source.

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22
Q

History and Physical Exam for GI Bleeding

Q: What factors should be assessed in the history of a patient with GI bleeding?

Q: What signs may indicate shock in a patient with GI bleeding?

A

A: The nature and duration of bleeding associated symptoms, past medical history (including previous PUD or AAA repair), medications, and symptoms of anemia should be evaluated.

A: Signs of shock, such as orthostatic changes, coagulopathy, chronic liver disease, malignancy, pallor, delayed capillary refill, and altered mental status, should be assessed.

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23
Q

History and Physical Exam for GI Bleeding.

Q: What findings may be observed during the abdominal examination of a patient with GI bleeding?

Q: What can be assessed during a digital rectal exam (DRE) in a patient with GI bleeding?

A

A: Abdominal tenderness and hepatosplenomegaly (enlargement of the liver and spleen) may be observed.

: A DRE can help identify external lesions, the presence of melena or blood, and palpable masses.

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24
Q

Discuss GI Bleeding Questions

A
  1. Site: Upper vs. Lower
  2. Duration
  3. Severity: mild, moderate, severe, life-threatening
  4. Ongoing vs. stopped
  5. Estimated Blood Loss
  6. Vital Signs; Query Shock
  7. Need for blood transfusion
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25
Q

Ideally the treatment of the patient with a serious GI Bleed is a Team Sport.

Discuss the treatment steps.

A
  1. Within Minutes: A&E Physicians = Interns, MOs, Attendings, etc.
    -Diagnose Upper GI bleeding
    -Triage according to risk
    -Stabilize patient: Start Resuscitation
    -Call GI and Surgery early
    -Initiate empiric therapy

Within the Hour: The job of GI and Surgery Providers
*Decide about timing of endoscopy
*Make diagnosis
*Treat underlying condition

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26
Q

Identifying high risk patients: ICU?

A
  1. Elderly
  2. HGB <8, PCV < 25
  3. Recurrent hematemesis, hematochezia
  4. Hemodynamic instability
  5. Comorbidities
    Heart
    Lungs
    Kidney
    Liver
  6. Strongly consider ICU admission
    -Must justify non unit admission
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27
Q

Identifying low risk patients:

Who can be sent home from triage or discharged from ICU or floor ?

A
  1. Patient characteristics
    *None of the pre-endoscopy factors that require ICU or monitored bed
  2. EGD findings
    v5low risk findings: MW tear, esophagitis, ulcer with clean base
  3. No hemodynamic instability
  4. Limited hematemesis
  5. Few/No comorbid conditions
  6. Good support system
  7. Consider “Triage” endoscopy
    EGD with MW tear or ulcer with clean base
  8. Consider outpatient management
    RCT evidence to suggest this is safe
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28
Q

Evaluation: History of Previous Illness (HPI) related to bleeding risks

A
  1. Previous GI Bleeding history
  2. Duration of bleeding
    acute history more ominous than chronic history
  3. Pain
    Not particularly helpful in absence of perforation
    ~30% bleeding ulcers have no antecedent pain
  4. Symptoms of hypovolemia
    Dizziness/Orthostasis
    Mental status changes
    Angina/dyspnea
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29
Q

Evaluation: History/Comorbidities

Outline Predictors of GI bleed related mortality

A

Liver disease
Coronary artery disease
Renal disease
Malignancy
COPD

30
Q

Evaluation: Previous Vascular Surgery Operations

A
  1. AAA repair with graft (Abdominal aortic aneurysm)
  2. Other vascular repairs?
  3. Need to rule out aorto-enteric fistula now
  4. Patient should have EGD/CT within minutes
    “Call us STAT!”
31
Q

Evaluation: Medications

A
  1. NSAIDs
    Increase risk 3-4X baseline
    Low dose ASA 2-3X
    Risk increases to 16-20X on coumadin+NSAID
  2. Clopidogrel: might be more important than ASA
  3. Coumadin
    -Why are they on it?
    -How high is the thrombotic risk?
    -Primary prophylaxis in afib is a low priority in setting of acute bleed
  4. Ethanol use
32
Q

Discuss Evaluation: Physical exam - I in GI bleeding.

A
  1. Vital signs
    Resting HR
  2. Orthostatic: Hypovolemia
    -Orthostasis (drop 20 mm Hg, Increase in HR ~20)
    -Requires a ~20%volume loss
    -Capillary refill time
33
Q

Classification of Hypovolemic Shock.

Review the table.

A

Class I-IV

Blood loss %: <15%, 15%-30%, 30%-40%, >40%

Pulse: <100, >100, >120, >140

BP: Normal, Minimal DECREASE, DECREASE, SIGNIFICANT DECREASE

34
Q

Discuss Resuscitation and Initial Management of GI bleeding.

A
  1. Airway: place patient in lateral position; prevent aspiration; intubate if necessary!
  2. Breathing: High flow Oxygen via mask
  3. Circulation: Are there symptoms and signs of hypovolemic shock?Pallor? Confusion? Mental status changes? 2 large bore cannulas, U-catheter, NGT, IV fluids while awaiting blood

Aim for urine output of 0.5mls/kg/hr.

Collect FBC, Renal Tests, Liver Tests, Coagulation profile, Crossmatch

CXR

**In exsanguinating bleeding, transfuse regardless of Hemoglobin level

Over-transfusion may be as damaging as under-transfusion*

**Transfuse platelets if actively bleeding & platelets <50x109/L

**Consider FFP (fresh frozen plasma) if actively bleeding and have a PTT/INR/APTT > 1.5times normal

Current consensus guidelines advise that correction of a moderate        coagulopathy (INR up to 2.5) should not delay endoscopy (no difference in      outcomes vs non-coagulopathic patients)
35
Q

Discuss *Restrictive versus Liberal transfusion?

A

*Restrictive versus Liberal transfusion?
NEJM 2013: Restrictive transfusion (when Hb <7) leads to better outcomes as compared to liberal transfusion (when Hb <9)
The Lancet 2015: No sig. difference in clinical outcomes

significantly lower mortality at 45 days; lower risk of death in some patient subgroups (e.g. cirrhosis, peptic ulcer); lower rates of further bleeding, lower rates of rescue therapy, lower overall complication rates

*Restrictive transfusion strategy: This approach involves transfusing red blood cells only when the hemoglobin level falls below a certain threshold, typically between 70 g/L to 90 g/L. The goal is to maintain a lower hemoglobin level and only transfuse when necessary1.

*Liberal transfusion strategy: In contrast, a liberal strategy aims to maintain a higher hemoglobin level, usually between 100 g/L to 120 g/L, with transfusions occurring when hemoglobin drops below 100 g/L

36
Q

Discuss Risk Assessment Scores in Patients with Upper GI Bleeds (UGIB).

*Glasgow Blatchford score

A
  1. Consider Glasgow-Blatchford & AIMS65 score at initial assessment

Uses only clinical data available at presentation and ranges from 0 to 23
Predicts need for intervention (endoscopy, blood transfusion, operation) in patients with UGIB

 Score 0 = low risk: can be managed as outpatient
 Score <6 Increased risk: manage as inpatient
 Score ≥6 High risk: transfusion and urgent endoscopy

A study showed GBS score of 0 could be safely managed as outpatients, with no readmissions for UGIB or deaths within a 6-month follow-up period

37
Q

Discuss Risk Assessment Scores in Patients with Upper GI Bleeds (UGIB).
-AIMS65 score

A

AIMS65 score
5 factors associated with increased inpatient mortality

  1. Albumin < 30 g/L
  2. INR > 1.5
  3. Altered Mental status (GCS < 14, disorientation, lethargy, stupor, coma)
  4. Systolic blood pressure ≤ 90 mmHg
  5. Age > 65 years

AIMS65 Score and Projected Mortality
O risk: 0%
1 risk: 1%
2 risks: 3%
3 risks: 9%
4 risks: 15%
5 risks: 25%

NOTE: Significant increase in mortality rates as the number of risk factors increases

Albumin was the single most predictive factor of mortality along with comorbidities.

The Glasgow-Blatchford Score has greater sensitivity and negative predictive value for low-risk bleeding.

A low AIMS65 score should not be used to dictate discharge.

38
Q

Risk Assessment Scores in Patients with Upper GI Bleeds (UGIB)
*Consider Rockall score after endoscopy

A

The Rockall score is a clinical scoring system used to predict the risk of rebleeding and mortality following an episode of upper gastrointestinal bleeding (UGIB) after endoscopy. The score is calculated based on several factors, including the patient’s age, presence of shock, comorbidities, diagnosis, and findings at endoscopy123.

Here’s a brief overview of how the Rockall score is determined post-endoscopy:

  1. Age: Points are given based on the age group (0 points for <60 years, 1 point for 60-79 years, and 2 points for ≥80 years).
  2. Shock: The presence and severity of shock are assessed (0 points for no shock, 1 point for pulse >100 bpm, 2 points for systolic BP <100 mmHg).
  3. Comorbidity: Points are assigned for specific comorbid conditions (0 to 2 points).
  4. Diagnosis: The endoscopic diagnosis contributes to the score (0 to 2 points).
  5. Major stigmata of recent hemorrhage: Points are given based on endoscopic findings (0 to 2 points).

A full (post-endoscopic) Rockall score of less than 3 indicates a low risk of rebleeding or death, and patients may be considered for early discharge.

A higher score suggests a greater risk and may warrant more intensive management2.

39
Q

Proton Pump Inhibitors in Non-variceal bleeds.
Q: What is the recommended PPI regimen for non-variceal upper GI bleeds if peptic ulcer disease (PUD) is found at upper endoscopy?

Q: What are the benefits of using PPIs in non-variceal upper GI bleeds?

A

A: The recommended PPI regimen for non-variceal upper GI bleeds, specifically if PUD is found at upper endoscopy, is Omeprazole 80mg IV STAT followed by an infusion at 8mg/hr for 72 hours.

A: PPIs, such as Omeprazole, reduce the risk of rebleeding and transfusion requirements in non-variceal upper GI bleeds.

40
Q

Q: Is there evidence supporting the use of H2 antagonists, like Ranitidine, in non-variceal upper GI bleeds?

A

A: There is no good evidence supporting the use of H2 antagonists, such as Ranitidine, in non-variceal upper GI bleeds.

41
Q

Oral PPI versus IV PPI.

Q: Are oral and IV proton pump inhibitors (PPIs) equally effective in reducing re-bleeding rates in non-variceal upper GI bleeds?

Q: Is continuous infusion of PPIs more effective than high-dose intermittent dosing in non-variceal upper GI bleeds?

Q: What is an example of a high-dose intermittent dosing regimen for IV PPIs?

A

A: Yes, studies have shown that re-bleeding rates were similar in both the IV-PPI and oral-PPI groups at 72 hours, 7 days, and 30 days.

A: No, continuous infusions of PPIs have not been shown to be more effective than high-dose intermittent dosing in terms of re-bleeding, need for operation, repeat intervention, or need for urgent intervention.

A: An example of a high-dose intermittent dosing regimen is omeprazole 40 mg IV every 12 hours.

42
Q

Q: Why is it important to consider the timing of upper GI endoscopy in non-variceal upper GI bleeds?

A

A: Performing endoscopy too early may not allow for adequate resuscitation and could result in worse patient outcomes. On the other hand, delaying endoscopy could also lead to worse outcomes due to ongoing bleeding.

43
Q

Q: What are the potential consequences of performing early endoscopy at off-hours?

Q: Why is delaying endoscopy in non-variceal upper GI bleeds concerning?

A

A: Early endoscopy may be performed at off-hours when fewer resources may be available, which could impact the availability of specialized personnel or necessary equipment.

A: Delaying endoscopy may result in worse patient outcomes due to ongoing bleeding. The timely identification and management of the bleeding source through endoscopy can help improve outcomes.

44
Q

Outline Indications for Urgent Endoscopy .

A
  1. Immediately after resuscitation:*Esophageal or gastric varices are suspected.*The patient continues to bleed.
  2. The patient remains hemodynamically “unstable” despite IV fluid resuscitation or transfusion. Query tachycardic, hypotensive?
  3. Age > 60 years
45
Q

Timing of Upper endoscopy

Q: When should upper GI endoscopy be performed in most patients with non-variceal upper GI bleeds?

Q: Are there any exceptions to the timing of upper GI endoscopy in non-variceal upper GI bleeds?

A

A: In most patients with non-variceal upper GI bleeds, upper GI endoscopy should be performed within 24 hours of presentation.

A: Yes, an exception is made for patients with a very low risk (i.e., Glasgow-Blatchford Score of 0), who may undergo endoscopy as outpatients.

46
Q

Q: What are the outcomes associated with immediate and early endoscopy (within 12 hours) in non-variceal upper GI bleeds?

A

A: Immediate and early endoscopy (within 12 hours of presentation) are associated with an increased use of endoscopic therapy without an overall improvement in clinical outcomes, including mortality, recurrent bleeding, or the need for surgical intervention, when compared with endoscopy performed within 24 hours.

*However, there may be a benefit of early endoscopy for select patients at higher risk of bleeding.

47
Q

Discuss Prognostic information from endoscopy“Stigmata of recent hemorrhage” (SRH) include high risk to low risk and the action to take?

A

High risk
Spurting vessel: Attempt treatment
Oozing vessel: Attempt treatment
Adherent clot: Attempt treatment

Dark spot: Observe ?

Low Risk
Clean Base: Send home ?

48
Q

NVGIB: Peptic ulcer disease

Define peptic ulcer disease.

State the risk factors for peptic ulcer disease.

What is the rate of mortality associated with acute bleeding from a peptic ulcer?

A

A break in the continuity of the mucosal lining of the stomach or duodenum.

The mortality associated with acute bleeding from a peptic ulcer remains high (5 to 10%).

4 risk factors:
*H. pylori infection
*NSAIDs
*Stress
*Gastric acid
*Alcoholism

49
Q

Bleeding Peptic Ulcers

Discuss FORREST: Classification of upper GIT hemorrhage

A

ACUTE BLEEDING
FORREST IA: Active spurting hemorrhage
FORREST IB: Oozing hemorrhage

SIGNS OF RECENT HEMORRHAGE
FORREST IIA: Non-bleeding visible blood vessels
FORREST IIB: Adherent clot
FORREST IIC: Hematin on ulcer base

LESIONS WITHOUT ACTIVE BLEEDING
FORREST III: Clean base ulcers

50
Q

Discuss Rockall Score

A

Helps predict risk of re-bleeding and mortality after upper GI bleeding.

The pre-endoscopy score is a more reliable predictor of mortality in peptic ulcer bleeding than the final score

51
Q

Non-variceal bleed - mortality

Q: What were the estimated mortality rates for non-variceal upper GI bleeds in the past?

Q: What does recent evidence suggest about in-hospital mortality in non-variceal upper GI bleeds?

Q: What is likely responsible for the decrease in mortality rates in non-variceal upper GI bleeds?

A

A: Estimated mortality rates for non-variceal upper GI bleeds were previously widely reported to be in the range of 5-14%.

A: Recent evidence suggests that in-hospital mortality in non-variceal upper GI bleeds has decreased to approximately 2%.

A: Advances in medical and endoscopic therapies are likely responsible for the decrease in mortality rates in non-variceal upper GI bleeds.

52
Q

Discuss Treatment Options at Upper Endoscopy.

A

Sclerotherapy: ethanol, ethanolamine. Injected to cause direct tissue injury and thrombosis

Injection: adrenaline, saline solution. Achieve tamponade effect

Cautery: argon photocoagulation, laser, electrocautery, Coagulate vessels

Mechanical therapy: endoclips (deployed over a visible vessel), band ligation (for variceal bleeding)

53
Q

Discuss Endoscopic Management Non-Variceal UGIB.

A

*Mechanical method (for example, clips) with or without adrenaline
*Thermal coagulation with adrenaline
*Fibrin or thrombin with adrenaline

54
Q

Management Recommendations Non-Variceal UGIB.

Q: What is the recommended management approach for “unstable” patients who re-bleed after endoscopic treatment for non-variceal upper GI bleeds?

Q: When is an operation required in the management of non-variceal upper GI bleeds?

A

A: In such cases, interventional radiology should be considered if available.

However, if interventional radiology is not promptly available, the patient should be urgently referred for an operation.

A: An operation may be required if endoscopy fails to arrest the bleeding and for patients at a projected high risk of rebleeding, particularly in elderly patients.

55
Q

Q: What are some surgical operations performed for non-variceal upper GI bleeds?

Q: What is the role of vagotomy in the management of non-variceal upper GI bleeds?

.

A

A: Some surgical operations performed for non-variceal upper GI bleeds include:

*Wedge resection of the stomach for gastric ulcers.
*Pyloromyotomy for bleeding duodenal ulcers, with under sewing of the bleeding gastroduodenal artery and closure transversely as a pyloroplasty.

NOTE: During a pyloromyotomy, the surgeon cuts a portion of the muscle fibers in the pyloric muscle. This loosens the tight muscle, allowing the stomach to empty properly, and food can then pass easily into the small intestine.

A: Vagotomy, which involves the ligation of vagal nerves to decrease gastric acid production, may be performed in conjunction with the aforementioned operations.

However, vagotomy is infrequently performed nowadays due to the availability of proton pump inhibitors (PPIs) and H2 blockers, which provide excellent acid secretion control

NOTE:
LIGATION The surgical process in which a string (LIGATURE) is placed tightly around a tissue and tied.

56
Q

Discuss Duodenal Ulcer with a Bleeding Gastroduodenal Artery

A

An ulcer in the posterior wall of the second part of the duodenum with a side hole in the GDA thwarting retraction and thrombosis.

57
Q

STOP and Always Ask. Could this be a variceal bleed?

Why?

A

Stakes are higher and treatment more difficult in the patient with portal hypertension and liver disease.

58
Q

Discuss Management of Variceal GIB.

Describe how varices occur?

A

Varices occur as a result of portal hypertension which leads to increases in portal pressure and development of portosystemic shunts

  1. ENDOSCOPIC MANAGEMENT

*Variceal band ligation (VBL)

*Cyanoacrylate and thrombin

*Balloon tamponade

*Esophageal stenting

*TIPSS and rebleeding: Transjugular Intrahepatic PortoSystemic Shunt
Rapidly reduce portal pressures by creating a portosystemic shunt across the liver parenchyma.
Superior to VBL for preventing rebleeding

59
Q

Describe Transjugular Intrahepatic Portosystemic Shunt procedure.

A

A: Insertion of a catheter guided needle passed from the internal jugular to right hepatic vein to puncture the portal vein.
B: Insertion of guide-wire into the portal system.
C: Dilatation of hepatic parenchyma between the portal vein and hepatic vein.
D: Stent placement in the newly formed tract

60
Q

Discuss post-endoscopic management of UGIB.
*Variceal UGIB
*Non-Variceal UGIB

A
  1. Variceal UGIB
    *Terlipressin: Terlipressin is an analogue of vasopressin used as a vasoactive drug in the management of low blood pressure.
    *Non-selective beta blockers
    *Book for endoscopy at 3 months, then 6-monthly thereafter.
    *TIPSS
  2. Non-Variceal UGIB
    *PPI therapy
    *H. pylori eradication
    *Transfusions
    *Iron replacement
    *Stop Antithrombotic therapy
61
Q

Discuss Lower GI bleed : Overview

A
  1. Evaluate and triage according to risk
    (Similar to UGI Bleed)
    Age, comorbid conditions, hemodynamics
  2. Stabilize: replace volume
  3. Call GI and Surgery Consultants early
62
Q

Lower GI Bleed - Overview
What is Hematochezia

A

A: Hematochezia is the term used to describe the passage of fresh blood through the rectum.

63
Q

Q: What are some patterns of lower GI bleeding and their associated causes?

A

A. Single, painless, massive bleeding: This pattern is commonly associated with diverticular bleeding.

Recurrent, painless bleeding: This pattern is often seen with arteriovenous malformations (AVMs).

Bleeding with pain and fever: Colitis, such as inflammatory bowel disease, can be a potential cause.

Rectal pain: Conditions such as anal fissures or hemorrhoids can cause rectal pain and bleeding.

Massive bleeding with shock: In some cases, a lower GI bleed with rapid transit may mimic an upper GI bleed, leading to massive bleeding and shock.

64
Q

Lower GI bleeding

Q: What are the most common causes of lower gastrointestinal (GI) bleeding?

Q: What are some less common causes of lower GI bleeding?

A

A: The most common causes of lower GI bleeding include diverticular disease and arteriovenous malformations (AVMs).

A:
Colitis (Inflammatory or infectious)
Tumors
Hemorrhoids
Miscellaneous ulcers
Ischemia

65
Q

Q: What is the nature of bleeding in diverticular disease?

A

A: In diverticular bleeding, the nature and color of the bleeding can vary. Right-sided diverticular bleeding is known to present clinically as dark, maroon-colored blood or melena-like.

66
Q

Q: What are some differential diagnoses to consider during the evaluation of lower GI bleeding?

A

A: During the evaluation of lower GI bleeding, it is important to consider other common causes such as colon cancer, angiodysplasia, post-polypectomy bleeding, internal hemorrhoids, inflammatory bowel disease, infectious colitis, ischemic colitis, and radiation proctitis.

67
Q

Discuss Management of LGIB

A
  1. Fluid resuscitation & continuous monitoring of volume status and response

Most LGIB stop spontaneously, and the majority require no further intervention other than initial resuscitation.

  1. If/when the bleeding stops, schedule for elective colonoscopy, also known as a lower GI Endoscopy.
68
Q

Discuss Lower GI Endoscopy Options

A
  1. Full colonoscopy – Visualize the entire large intestine to the ileocecal valve and appendiceal orifice and seek to intubate and visualize the terminal ileum.
    BUT: Requires a bowel prep, sedation and/or general anesthesia.
  2. Flexible sigmoidoscopy: view the distal quarter of the colon, rectum, and anorectal area but not the proximal three fourths of the colon.
  3. Rigid sigmoidoscopy or proctosigmoidoscopy: view the distal 25 cm.
  4. Anoscopy: view the anorectum to rule in or out bleeding hemorrhoids, ulcers, or neoplasms, etc.
69
Q

Discuss Endoscopic evaluation of lower GI bleed with hemodynamic compromise.

A
  1. EGD
    rule out upper bleed
    (bonus: preclude surgical confusion and plausible deniability)
  2. Colonoscopy:
    Sometimes: limited lower exam without prep
    Can we regionalize the bleeding (i.e. left colon with blood/ proximal colon without blood)
    “Rapid purge” and definitive lower exam
    Golytely when stabilized
70
Q

Discuss Some operations for LGIB.

A

Emergent and urgent operations are reserved for persistent, life-threatening bleeding.

Ideally the goal is to “stabilize” the patient hemodynamically to permit further investigations and discern the cause and location of the bleeding.

Operation may well entail partial:

-Subtotal colectomy and possibly the creation of a stoma, e.g., a colostomy or ileostomy.

71
Q

Discuss Obscure or Cryptic GI Bleeding

A

If bleeding cannot be localized by upper or lower GI endoscopy, i.e., there are negative, non-diagnostic EGDs and colonoscopies then depending on the rate of bleeding and the patient’s condition consider:
Mesenteric angiogram +/- embolization
Capsule endoscopy
Double balloon enteroscopy
Nuclear Medicine studies, e.g.,
Technetium-labelled RBC scan

72
Q

Some Take Home Messages

Patients deserve a multidisciplinary team, ideally with gastroenterologists, surgeons, anesthesiologists, and radiologists plus strong lab and blood bank backup.

Massive UGIB may cause bright red blood per rectum = hematochezia.

Resuscitate in a goal directed fashion; endeavor not to over-resuscitate.

Have a system, an algorithm, for workup and management.

Use IV/Oral PPIs for UGIB pre-endoscopy and continue after EGD if PUD diagnosed.

Immediate EGD if high risk or possible variceal UGIB, otherwise within 24hrs.

Localize the bleeding site preoperatively if the patient’s condition permits. Consider angiography for localization and treatment if the patient a candidate hemodynamically and interventional radiology is available.

Operate for persistent or recurrent bleeding post endoscopy or if demise imminent.

A

SOM 309 (313): GASTROINTERSTINAL DISEASES (28 decks)

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