GI bleeding

Question 1

What is the differentiation point for the upper and lower GI bleeding?

Answer 1

Ligament of Trietz (LoT) is at the duodenojejunal junction

-Upper GI bleed
From a source above the LoT

-Lower GI bleed
From a source below the LoT

Question 2

Presentation of Upper GI bleeding

4

Answer 2

1. Hematemesis
2. Blood or coffee grounds detected during nasogastric lavage
3. Melena
4. BUN to serum creatinine ratio greater than 30

Question 3

Presentation of Lower GI bleeding

3

Answer 3

1. Blood clots in the stool
2. Red blood that is mixed with solid brown stool
3. Dripping of blood into the toilet after a bowel movement

Question 4

1. Hematemesis will look like what?
2. Melena can occur with just how much blood loss in the upper GI tract?
3. Hematochezia is what color?
4. Hematochezia is generally caused by what but can also be caused by?

Answer 4

1. Red or brown flakes like coffee grounds
2. 50-100 mL of blood
3. Red or maroon colored stool
4. Generally from a lower GI source but can occur with a loss of more than 1000 mL of blood in the upper GI tract

Question 5

What causes coffee-ground emesis?

Answer 5

Blood sitting in the stomach acid causes the iron to oxidize resulting in the appearance of coffee ground like flakes

Question 6

Describe the following for Upper GI bleeds and also for Lower GI bleeds:
1. Severity?
2. Site?
3. Presentation? 
Upper- 3 
Lower -1
4. Nasogastric lavage?
5. Bowel sounds?
6. BUN:Creat ratio?

Answer 6

Upper GI Bleed
(2/3 of cases of GIB)
1. More likely to have significant bleeding
2. Above the Ligament of Trietz
3. 
-Hematemesis, 
-melena,
-Hematochezia with massive UGI of  > 1000  mL
4. Blood
5. Hyperactive
6. > 30:1

Lower GI Bleed

1. Less likely to present with shock or require transfusion
2. Below the Ligament of Trietz
3. Hematochezia
4. Clear fluid
5. Normal
6. Normal

Question 7

Review: Where does BUN come from?

5 steps

Answer 7

1. When protein is used for energy the carbon is cleaved from the amino acid and leaves behind a Nitrogren.
2. The N takes up 3 H+ to form NH3+ which is ammonia.
3. The ammonia (NH3+) is then processed through the liver to become urea.
4. When the urea enters the blood stream it is called the blood urea nitrogren.
5. The blood urea nitrogren is then excreted by the kidney

Question 8

BUN increases when protein is broken down and more ammonia forms
Examples? 6

Answer 8

1. Burns
2. Tetracycline
   3 Steroids
3. Fever
4. Catabolic state
5. Upper GI bleeding

Question 9

How does Upper GI bleeding cause increased BUN?

Answer 9

(breakdown of the hemoglobin protein by the stomach acid, enzymes)

Question 10

Etiology of Upper GI bleeds?
(in order of prevelance)
8

Answer 10

1. Peptic ulcer dz 50%
2. Portal HTN 20%
3. Mallory-Weiss Tear 10%
4. Vascular anomalies 7%
5. Others 6%
6. Erosive Gastritis 5%
7. Erosive esophagitis 1%
8. Gastric neoplams 1%

Question 11

1. Portal HTN is most commonly caused by?

2. Results in formation of what? 3

Answer 11

1. Most common cause is cirrhosis
2. Results in formation of
   - esophageal,
   - gastric and
   - duodenal varices that can rupture

Question 12

1. What is a mallory weiss tear?
2. Most often caused by?
3. Other causes? 6

Answer 12

1. Laceration of the gastroesophageal junction
2. Often report a history of retching which may be due to heavy drinking
3. • Seizure,
   • childbirth,
   • coughing,
   • straining,
   • defecation,
   • weight lifting

Question 13

Vascular anomalies that cause UGI bleeding?

2

Answer 13

1. Angiodysplasia

2. Telangectasias

Question 14

1. Angiodysplasia are what?

2. Telangectasias associated with what?

Answer 14

1. Small AV malformations

2. Associated with connective tissue disease like CREST syndrome and HHT

Question 15

1. Erosive gastritis is usually described as what kind of bleeding?
2. Erosive esophagitis secondary to what?

Answer 15

1. Usually superficial bleeding that does not lead to acute significant blood loss
2. Secondary to chronic reflux

Question 16

“Other” causes of UGI

5

Answer 16

1. Aortoenteric fistula
2. Hepatic tumor
3. Angioma
4. Penetrating trauma
5. Pancreatic malignancy

Question 17

Other causes of UGI: Aortoenteric fistula. What is it?

Answer 17

Complication post abdominal aortic aneurysm (initial presentation or post graft placement)

Question 18

Etiology of LGI bleeding

1. If age younger than 50? 3
2. If age older than 50? 4

Answer 18

1. Age 50
   - Diverticulosis
   - Agioectasias
   - Malignancy
   - Ischemia

Question 19

Etiology of Lower GI bleeding
Diverticulosis:
1. Causes what % of LGIs?
2. What increases the risk of bleeding with diverticulosis? 2
3. Presents how?

Answer 19

1. Causes 50% of LGIs
2. ASA and NSAIDs
3. Acute, painless, large volume maroon or bright red hematochezia

Question 20

Etiology of Lower GI bleeding:
Angioectasias
1. Presents how?
2. Most common in what ages?

Answer 20

1. Painless bleeding in the upper or lower GI tract

2. Most common in > 70 years

Question 21

Anorectal disease causes of LGI? 2

What will it look like?

Answer 21

1. Hemorrhoids and fissures

2. Bright red blood noted on toilet paper, blood streaked stool or blood dripping into toilet

Question 22

Ischemic colitis

1. Most often in pts with what?
2. Can be a complication of what?
3. When would it be seen in younger pts?

Answer 22

1. Most often older patients with atherosclerotic disease
2. Can be a complication of aortic surgery
3. Can be seen in younger patients post long distance running

Question 23

When would Radiation induced proctitis present?

Answer 23

Months to years post pelvic radiation

Question 24

Initial management of bleeds

3

Answer 24

1. Stabilization
2. Blood replacement
3. GI consult for Upper or lower endoscopy

Question 25

Assess the degree of bleeding from SBP and HR 1. Severe? 2. Moderate? 3. Minor bleeding?

Answer 25

1. Severe bleeding SBP less than 100 mmHg HR > 100 2. Moderate bleeding SBP > 100 mmHg HR > 100 3. Minor bleeding Normal HR and BP

Question 26

Labs for bleeding? | 4

Answer 26

1. CBC - -May take 24 hours to reflect the degree of blood loss 2. PT/INR 3. CMP 4. Blood type and screening

Question 27

Stabilization of bleeding? 4

Answer 27

1. 2 large bore IV’s 2. NS or Lactated Ringer solution 3. Nasogastric tube +/- 4. IV proton pump inhibitor for UGI

Question 28

Why would we consider a nasogastric tube?

Answer 28

Can lavage with saline and aspirate contents looking for blood to confirm upper source

Question 29

If due to varices from portal HTN then can give what? | 2

Answer 29

IV octreotide or somatostatin to reduce splanchnic blood flow and portal pressures

Question 30

Transfusion 1. Usually target is to maintain Hgb of what? 2. How much should Hgb go up per each unit transfused? 3. Give one unit of FFP for each _______ of packed red blood cells 4. Transfuse platelets if

Answer 30

1. 7-10 g/dL 2. 1 g/dL for each unit transfused 3. 5 units 4. 1.8 6. DDAVP

Question 31

Endoscopy 1. Unless very unstable usually prefer to do a what? 2. Upper endoscopy, can help enhance stomach emptying by the administration of what? 3. Endoscopy can be both...?

Answer 31

1. bowel prep if colonoscopy is needed 2. IV erythromycin 3. diagnostic as well as therapeutic

Question 32

What kind of therapeutic measures can we take with endoscopy? 2

Answer 32

1. Sclerosis or banding of varices | 2. Cautery of bleeding vessels

Question 33

Treatment: | Depending on the underlying cause of the GI bleeding? 3

Answer 33

1. May require surgical repair 2. Intra-arterial embolization (done percutaneously) 3. Decompression of the portal vein with a shunt placement if varices are not manageable

Question 34

1. If abdominal pain and periotoneal signs consider there is a what? 2. If may take the HCT __ hrs or more to reflect the current state of blood volume, so act clinically

Answer 34

1. Bowel of esophageal perforation | 2. 24

Question 35

The higher the BUN:creat ratio the more likely the bleeding is from what?

Answer 35

upper GI source

Question 36

1. Acute blood loss anemia? | 2. Chronic?

Answer 36

1. Normocytic/ Just low | 2. Microcytic