Upper GI Bleeding - Low/Med Priority

Question 1

What is UGIB?

Answer 1

refers to bleeding that starts in the esophagus, stomach or duodenum
-it is a potentially fatal condition with mortality rate of 3-14%
-occurs ~4x more than lower GI tract bleeding

Question 2

What is death from UGIB mainly due to?

Answer 2

comorbid illnesses

Question 3

What occurs to majority of UGIB without treatment?

Answer 3

80% spontaneously resolve without treatment

Question 4

What are the classifications of UGIB?

Answer 4

variceal bleeding:
-related to end-stage liver disease
nonvariceal bleeding:
-other causes of UGIB (e.g. PUD)

Question 5

What is the second most common cause of UGIB?

Answer 5

variceal bleeding

Question 6

Where does variceal bleeding tend to occur?

Answer 6

distal esophagus

Question 7

What are esophageal varices?

Answer 7

hypertensive portal vein and hepatic cirrhosis obstructs venous blood flow and increases pressure

Question 8

What are the risk factors for variceal bleeding?

Answer 8

increased size of varices
severity of liver disease
prior variceal hemorrhages

Question 9

What is the most common cause of UGIB?

Answer 9

PUD

Question 10

What are the two types of PUD?

Answer 10

duodenal ulcers
gastric ulcers

Question 11

Why does PUD mainly occur?

Answer 11

H. pylori infection or chronic NSAID use

Question 12

In which patients do stress-related ulcers occur in?

Answer 12

hospitalized and/or critically ill
-high mortality rate

Question 13

What are the risk factors for stress-related ulcers?

Answer 13

mechanical ventilation
coagulopathy
surgery
sepsis
burns
trauma

Question 14

What are Mallory-Weiss Tears?

Answer 14

longitudinal gastric mucosal tear that are self-limited
-coughing, retching, and/or vomiting followed by hematemesis
-relate to increase in intra-abdominal pressure

Question 15

What are the risk factors for Mallory-Weiss Tears?

Answer 15

excess alcohol use
DKA
hiatal hernias

Question 16

What is the clinical presentation of UGIB?

Answer 16

hematemesis
-coffee-ground emesis resulting from acid hemolysis
melena
-black, tarry stool
hematochezia
-bright red or maroon coloured blood coming from rectum
occult GI bleeding
-use of fecal occult blood test or iron deficiency, no obvious bleeding
symptoms of hemorrhage
-lightheaded, tachycardia, angina, dyspnea, syncope

Question 17

What are the goals of therapy for UGIB?

Answer 17

minimize morbidity and mortality
identify the root cause of the hemorrhagic event
stabilize and treat the culprit lesion
prevent recurrences
prevent adverse effects from pharmacotherapy

Question 18

What are the non-pharmacological measures for UGIB?

Answer 18

resuscitate and stabilize
-fluid resuscitation and perfusion
-crystalloids (e.g. 0.9% NaCl, Ringers)
transfusion with HgB
urgent endoscopy +/- hemostatic therapy if life-threatening

Question 19

When is transfusion with HgB done for UGIB?

Answer 19

HgB < 80 g/L or pt is unstable with frank hemorrhage

Question 20

Which class of medication is used to manage nonvariceal bleeding?

Answer 20

PPIs

Question 21

When are IV PPIs used for nonvariceal bleeding?

Answer 21

use pre-endoscopy and post-endoscopy in pts with high-risk stigmata

Question 22

When are oral PPIs used for nonvariceal bleeding?

Answer 22

outpatients and post IV therapy inpatients

Question 23

Describe the use of IV PPIs for nonvariceal bleeding.

Answer 23

pantoprazole 80 mg bolus followed by continuous infusion 8 mg/h for 72 hrs OR pantoprazole 40 mg IV BID

Question 24

What is the benefit of PPIs in the setting of nonvariceal bleeding?

Answer 24

reduces recurrent bleeding, risk of surgery compared to H2RA

Question 25

What is the role for H2RAs in the management of nonvariceal bleeding?

Answer 25

not recommended

Question 26

Which pharmacological classes are used to manage variceal bleeding?

Answer 26

antibiotics vasoactive drugs (octreotide, vasopressin, nitroglycerin)

Question 27

How long is antibiotic prophylaxis used for variceal bleeding?

Answer 27

antibiotic prophylaxis: administer for 3-7 days

Question 28

Which antibiotics are used prophylactically in the setting of variceal bleeding?

Answer 28

oral norfloxacin oral or IV ciprofloxacin IV 3rd gen cephalosporin -preferred in advanced liver diseases or areas with high FQ resistance

Question 29

When should antibiotic prophylaxis be started for variceal bleeding?

Answer 29

upon admission to hospital -~20% are admitted with a bacterial infection -~50% will develop peritonitis

Question 30

What is the benefit of antibiotic prophylaxis in variceal bleeding?

Answer 30

reduces risk of recurrent bleeding, bacterial infection, and mortality

Question 31

How long are vasoactive drugs administered for variceal bleeding?

Answer 31

3-5 days

Question 32

What is the 1st line vasoactive drug for variceal bleeding?

Answer 32

octreotide

Question 33

What is the MOA of octreotide?

Answer 33

somatostatin analogue -reduces variceal blood flow

Question 34

What is the place in therapy for vasopressin and nitroglycerin in variceal bleeding?

Answer 34

not as effective or safe as octreotide

Question 35

Which medications are used for prevention of variceal bleeding?

Answer 35

non-selective BB -nadolol, propranolol *may be used as monotherapy or in combination with endoscopic variceal ligation to prevent recurrent bleeds*

Question 36

When is variceal prophylaxis used?

Answer 36

pts with portal hypertension and esophageal varices

Question 37

What is monitored as a surrogate marker when using beta-blockers for variceal prophylaxis?

Answer 37

heart rate

Question 38

After how long can BID PPI regimens be stepped down to once daily?

Answer 38

after 2 weeks of therapy