What anatomical location defines upper GI bleeding from lower GI bleeding?
Ligament of Treitz in small intestine
What are (10) main causes of upper GI bleeds?
- Peptic ulcer disease
- Reflux esophagitis
- Esophageal varices
- Gastric varices
- Gastric erosions, duodenitis
- Mallory-Weiss tear
- Hemobilia
- Dieulafoy vascular malformation
- Aortoenteric fistulas
- Neoplasms
What are the (3) subcategories of peptic ulcer disease and their prevalance?
- Duodenal ulcer (25%)
- Gastric ulcer (20%)
- Gastritis (25%)
What is one vascular malformation that may cause massive GI bleeds in the upper GI system and what layer is it located?
Dieulafoy vascular malformation; submucosal dilated arterial lesion
What are (8) main causes of lower GI bleeds?
- Diverticulosis
- Angiodysplasia
- IBD
- Colorectal carcinoma
- Colorectal adenomatous polyps
- Ischemic colitis
- Hemorrhoids, anal fissures
- Small intestinal bleeding
What is the most common cause of lower GI bleeds? What age range does it usually appear? Is it painful or painless?
Diverticulosis in patients >60 yo with painless bleeding
What do the following types of bleeding indicate about their origin?
- Hematemesis
- “Coffee grounds”
- Melena
- Hematochezia
- Hematemesis - upper GI
- “Coffee grounds” - upper GI, lower rate of bleeding
- Melena - upper GI, longer instestinal transport
- Hematochezia - lower GI, left colon/rectum
What (3) medications are important to ask about in a patient reporting GI bleeding?
- NSAIDs/aspirin
- Clopidegrel
- Anticoagulants
What (4) diseases might an elevated PT indicate in a patient presenting with a GI bleed?
- Liver dysfunction
- Vitamin K deficiency
- Consumptive coagulopathy
- Warfarin use
What initial tests should be ordered for a patient presenting with:
- Hematemesis
- Hematochezia
- Melena
- Occult blood
- Hematemesis - upper GI endoscopy
- Hematochezia - r/o anorectal cause –> colonoscopy
- Melena - upper endoscopy; if (-) f/u w/colonoscopy
- Occult blood - colonoscopy; if (-) f/u w/endoscopy
What is the first laboratory value that should be evaluated for with occult blood presentation?
Iron deficiency anemia
What size RBC are present with acute bleeding?
Normocytic
What happens to the BUN:Cr in upper GI bleeds? What must be assumed for this association to apply?
Elevated in patients with normal renal function
What is the most accurate diagnostic test in evaluating upper GI bleeds?
Endoscopy; diagnostic and therapeutic (can coagulate bleeding vessels)
What should be performed to exclude anal/rectal source of bleeding if there are no obvious bleeding from hemorrhoids?
Anoscopy or proctosigmoidscopy
What is the role of a radionuclide scan when evaluating GI bleeds? What are it’s limitations?
Used to detect bleeding even in low rates of blood loss. Cannot localize lesion // only identifies continued bleeding
What imaging study is used to definitively identify origin of bleeding in GI bleeds? When is it used?
Arteriography - normally used in lower GI bleed evaluation when there is active bleeding
In upper GI bleeds, what imaging study and medications are started?
EGD - can coagulate bleeding vessel
PPI - increase pH promotes clotting
Octreotide - vasoactive in varices treatment
