GI Bleeding

Question 1

Hematemesis

Answer 1

bright red blood in vomit, or coffee ground type material

Question 2

Melena

Answer 2

black, tar like stool

Question 3

Hematochezia

Answer 3

BRBPR (bright red blood per rectum), usually lower, but if

massive upper GIB, can have this

Question 4

Esophagus spinal level

Answer 4

T2-T8

Question 5

Spinal level for Upper GI Tract

Stomach, Liver, Gallbladder, Spleen, Portions of Pancreas and Duodendum

Answer 5

T5-T9, Greater Splanchnic Nerve Celiac Ganglion

Question 6

Spinal level for Middle GI Tract

Portions of Pancreas and Duodenum, Jejunum, Ileum, Ascending Colon, and 2/3 of Transverse Colon

Answer 6

T10-T11, Lesser Splanchnic Nerve Superior Mesenteric Ganglion

Question 7

Lower GI Tract

Distal 1/3 of Transverse Colon, Descending Colon and Sigmoid Colon, Rectum

Answer 7

T12-L2, Least Splanchnic Verse Inferior Mesenteric Ganglion

Question 8

Acute upper GI bleed can be from

Answer 8

• Peptic Ulcer Disease (H pylori)
• Portal Hypertension: 10-20% of cases; can be massive due to esophageal or gastric varices; pressures in portal system, draining into liver, esophageal varices are very risky if they start bleeding
• Mallory Weiss tear

Question 9

Initial step for acute GI bleed

Answer 9

• NG tube? Gastric Lavage?
• Rectal?
• Hemodynamic Stabilization
• -BP Systolic 100 response to acute
• -blood loss, first vital sign of change
• HCT takes 24-72 hours to equilibrate
• Two large 18 gauge IV’s
• Type and Screen, CBC, INR/PT/PTT, CMP
• 0.9% NS until blood ready, if needed can use O – blood universal donor
• ICU? Central line?
• Give bolus of IV saline until you can see what hemoglobin levels are

Question 10

Goal of hemoglobin?

Answer 10

New guidelines:

• 7 is threshold now, unless cardiac history then consider goal of >9 (if having MI; want to increase oxygenation to cardiac muscle)
• Platelets > 50,000

-Warfarin? INR high? Give FFP
Note: massive transfusion can have dilutional effect on INR/PT/PTT, consider 1 unit of FFP for each 5 units of PRBC

Question 11

Uremia? End Stage Renal Disease patient? Consider _________

Answer 11

DDAVP (desmopressin acetate, synthetic ADH)

-in pts with uremia, platelets are there but don’t stick together well bc of uremia, DDAVP helps promote platelet adhesion, makes them sticky again

Question 12

History items to consider during acute upper GI bleed

Answer 12

• Aspirin? Cant reverse- takes 10-14 days to get our of your system (Clopridogrel and ASA- platelets are irreversibly inhibited)
• NSAIDS? Cant reverse
• NOAC? Novel oral anticoagulation
• Cirrhosis? Think esophageal varices

-WHEN WAS THE LAST DOSE TAKEN?

Question 13

Role of upper endoscopy in acute upper GI bleed

Answer 13

• Stabilize patient first hemodynamically
• Cautery, injection, endoclips
• Banding varices
• Bleeding ulcer or vessel: vessel they can clip, clips fall off on their own
• Put rubber bands on esophageal varices to prevent them from bleeding/rupturing

Question 14

Pharmacologic therapy for acute upper GI bleed

Answer 14

-IV PPI (bolus then drip for 72 hours)
-Consider PO PPI if low risk features
-Octreotide: gastric varices in liver patients, prevent them from bleeding worse if they have a small bleed- given IV
Patient’s with esophageal or gastric varices, liver disease, portal HTN; Reduces splanchnic blood flow and portal blood pressures

Question 15

Long term side effects with PPI use

Answer 15

• Potential decrease in non heme iron absorption with PPI has not been well studied
• No good evidence to support PPI use affecting bone density or osteoporosis related fractures
• ~50 cases of hypomagnesemia associated with PPI use
• FDA recommended consider checking magnesium level before starting long term PPI therapy

Question 16

Acute lower GI bleed

Answer 16

• Hematochezia
• 10% due to upper source
• Lower definition: below ligament of Treitz

Question 17

Causes of acute lower GI bleed

Answer 17

• Diverticulosis (can erode a blood vessel and bleed; acute, painless, large volume possible)
• Angioectasia: more common in CKD/ESRD patients
• Neoplasms
• IBD
• Anorectal disease (hemorrhoids, fissures)
• Ischemic Colitis (older pt, nonocclusive ischemia, usually self limited)
• Radiation induced proctitis (can irritate mucosa)

Question 18

Test for acute lower GI bleed

Answer 18

-Exclude upper GIB (NGT, lavage)
-Rectal Exam
-Colonoscopy or sigmoidoscopy
(Prep with GoLYTELY 3.8L)
-NM PRBC Scan (if positive, next step is angiography; Localization is poor, and

Question 19

Crohn’s vs UC: Site of origin

Answer 19

C- terminal ileum

UC- rectum

Question 20

Crohn’s vs UC: Pattern of progression

Answer 20

C- Skip lesions/irregular

UC- proximally contiguous

Question 21

Crohn’s vs UC: Thickness of inflammation

Answer 21

C- transmural (across wall)

UC- submucosa or mucosa

Question 22

Crohn’s vs UC: Symptoms

Answer 22

C- crampy abdominal pain

UC- bloody diarrhea

Question 23

Crohn’s vs UC: Complications

Answer 23

C- fistulas, abscess, obstruction

UC- hemorrhage, toxic megacolon

Question 24

Crohn’s vs UC: Radiographic findings

Answer 24

C- string sign on brain X-ray

UC- lead pipe colon on barium X-ray

Question 25

Crohn's vs UC: Risk of colon cancer

Answer 25

C- slight increase | UC- marked increase

Question 26

Crohn's vs UC: Surgery

Answer 26

C- for complications such as stricture | UC- curative (take out whole colon to rule out cancer, use colostomy bag)

Question 27

Transfusion in acute upper GI bleed

Answer 27

- Restrictive strategy group threshold of 7 g/dl (Goal 7-9) - Liberal group threshold of 9 g/dl (Goal 9-11) - Mortality at 45 days lower in restrictive strategy group 23/444 vs. 41/445 - Subgroup with cirrhosis, risk of death was lower in restrictive strategy group 15/139 vs. 25/138

Question 28

New anticoagulants in GI bleed

Answer 28

Pradaxa – dabigatran Xarelto – rivaroxaban Eliquis - apixaban -metabolized in kidney, warfarin is in liver -Expensive, don’t have to get INR checked regularly Coumadin, Warfarin take 72 hours to become activated and work - These meds start working within hours- advantage if you are already bleeding- within 24-48 hrs they are out of your system - Direct factor 10a inhibitors (3 of them) - Block thrombin (1 of them)

Question 29

see slide 26

Answer 29

see slide 26

Question 30

New anticoagulant risks

Answer 30

- Lower risk of hemorrhagic stroke brain bleed | - Higher risk of GI bleed

Question 31

When to resume Warfarin after GI bleed

Answer 31

- GIB defined by HGB drop by 2 grams, visible bleeding, or positive endoscopic evaluation - Restarting warfarin after 7 days was NOT associated with increased risk of GIB, but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption.

Question 32

Put older people on anti platelet therapy to prevent

Answer 32

them from bleeding (on steroids, NSAIDS, put them on pentoprazol to prevent a bleeding ulcer, even with the risk of C diff)

Question 33

INR goal of 2-2.5 is recommended for

Answer 33

-Combination of aspirin and heparin/LMWH/warfarin or clopidogrel

Question 34

Use of low dose aspirin for cardiovascular prophylaxis associated with

Answer 34

2-4 fold increase in upper gastrointestinal events -AHA recommends low dose aspirin in patient with 10 year cardiovascular risk > or = 10% -Full 325 ASA for prevention- very high bleeding risk- don’t need to use this 81 mg does just as good and has LOWER bleeding risk

Question 35

Gastric ulcer indication

Answer 35

Greater pain with meals

Question 36

Duodenal ulcer indication

Answer 36

Decreased pain with meals

Question 37

Ischemic colitis indication

Answer 37

post-prandial abdominal pain, older patient, hematochezia

Question 38

H2 blockers

Answer 38

famotidine, ranitidine – Block H2 receptors of parietal cells

Question 39

PPIs

Answer 39

omeprazole, pantoprazole - Inhibit H+/K+ ATPase in parietal cells - Low magnesium levels possible with long term use, higher risk of C diff

Question 40

Magnesium

Answer 40

Makes you go, take for constipation

Question 41

Aluminium

Answer 41

minimum amount of feces, take for diarrhea

Question 42

Osmotic laxatives

Answer 42

PEG, lactulose