GI Bleeding

Question 1

Initial evaluation of GI bleeding?

Answer 1

1. History and Physical points to Source/Etiology
2. History of Present Illness
3. Attention to PMHx, Social Hx, Medications

Question 2

History in GI bleeding?

Answer 2

1. Hematemesis (coffee grounds vs. bright red)
2. Hematochezia - bright red stained stool
3. Melena - dark, tarry stool
4. Pain symptoms
5. Medications – NSAIDs, steroids, ASA, clopidogrel, warfarin, Heparin, Iron
6. PMHx - arthritis, ulcer disease, EtOH

Question 3

Physical exam of GI bleeding?

Answer 3

1. HR, BP, RR, O2 saturation
2. General appearance, Mental status
3. Neck veins, oral mucosa
4. Skin temperature and color
5. Abdominal exam
6. Rectal
7. Stigma of Cirrhosis
8. NG Tube findings (upper vs. lower g.i. source)
9. Urine output

Question 4

Sources of GI bleeding?

Answer 4

1. Upper GI Tract
   - Proximal to the Ligament of Treitz
   - 70% of GI Bleeds
2. Lower GI Tract
   - Distal to the Ligament of Treitz
   - 30% of GI Bleeds

Question 5

Localization of bleeding?

Answer 5

1. History
2. NG Tube
3. EGD
4. Colonoscopy
5. Tagged RBC Scan
6. Angiography

Question 6

Presentation of upper GI bleed?

Answer 6

1. 50% present with hematemesis
2. NGT with positive blood on aspirate
3. 11% of brisk bleeds have hematochezia
4. Melena (black tarry stools)
   - this develops with approximately 150-200cc of blood in the upper GI tract
   - Stool turns black after 8 hours of sitting within the gut.

Question 7

Risk factors of upper GI bleed?

Answer 7

1. NSAID use
2. H. pylori infection
3. Increased age

Question 8

Etiology of upper GI bleeding?

Answer 8

1. Duodenal Ulcer-30%
2. Gastric Ulcer-20%
3. Varices-10%
4. Gastritis and duodenitis-5-10%
5. Esophagitis-5%
6. Mallory Weiss Tear-3%
7. GI Malignancy-1%
8. Dieulafoy Lesion - large tortuous arteriole running close to the mucosa of the stomach
9. AV Malformation-angiodysplasia

Question 9

What is esophagitis?

Answer 9

Inflammation that damages the tube running from the throat to the stomach (oesophagus)
Causes include
1. stomach acids backing up into the tube
2. infection
3. some medication
4. allergies

Question 10

What is an esophageal tumor?

Question 11

What is gastric carcinoma?

Question 12

What is angiodysplasia?

Question 13

Presentation of lower GI bleeding?

Answer 13

1. Hematochezia
2. Blood in Toilet
3. Clear NGT aspirate
4. Normal Renal Function
5. Usually Hemodynamically stable
   - Only 1/3 of patients with lower GI bleeds have positive orthostatics (tilt test).

Question 14

Etiology of lower GI bleeding?

Answer 14

1. Diverticular-20%
2. AVM-10%
3. Malignancy-2-26%
4. Inflammatory Bowel Disease-10%
5. Ischemic Colitis
6. Acute Infectious Colitis
7. Radiation Colitis/Proctitis
8. Aortoenteric Fistula

Question 15

What is diverticulosis?

Question 16

What are colonic polyps?

Question 17

Name malignant causes of lower GI bleeding?

Answer 17

colon carcinoma

Question 18

What are hemorrhoids?

Question 19

Management of GI bleed?

Answer 19

1. Oxygen
2. IV Access-central line or two large bore peripheral IV sites
   - Intravenous fluid for volume resuscitation
   - Start transfusing blood products if the patient remains unstable despite fluid boluses.
3. Airway Protection
   - Altered Mental Status and increased risk of aspiration with massive upper GI bleed
4. ICU admit indications
   Significant bleeding with hemodynamic instability
5. Transfusion

Question 20

Transfusion in GI bleed?

Answer 20

Brisk Bleed, transfusing should be based on hemodynamic status, not lab value of Hgb.
Cardiopulmonary symptoms-cardiac ischemia or shortness of breath, decreased pulse ox
1 unit PRBC increases Hgb by 1mg/dL and increase Hct by 3%
FFP for INR greater than 1.5
Platelets for platelet count less than 50K