Gastrointestinal Bleeding

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Gastrointestinal Bleeding
2013-10-22 20:25:27
Gastrointestinal Bleeding

Gastrointestinal Bleeding
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  1. What are some general characteristics of active upper GI bleeding?
    • -7-10% mortality
    • -Hematemesis, melena, or BRBPR
    • -Melena: 50-100ml blood loss in upper GI tract
  2. When upper GI bleeding is present, what are some of the causes and frequencies of occurrence?
    • -Peptic ulcer disease (PUD) -> (>50%)
    • -Portal HTN: Esophageal bleeding most common (10-20%)
    • -Mallory Weiss tears (5-10%)
    • -Vascular ectasias (7%)
    • -Gastric neoplasms (1%)
    • -Erosive gastritis/esophagitis (<5%)
  3. What do you need to do during a UGI bleeding assessment?
    • - Orthostatic blood pressure and pulse
    • - Resuscitation if unstable
    • -NG tube: red or coffee ground aspirate confirmes upper GI bleed
  4. How do you administer an upper endoscopy (EGD)?
    • -Identify source of bleed
    • -Determine risk of rebleeding
    • -Render endoscopic therapy ->Cautery ->Clips ->Injection
  5. What pharmacologic treatment is administered to patients for UGI bleed?
    • -Proton Pump Inhibitors
    • -Octreotide
  6. Give some general information concerning Acute Lower GI Bleeds.
    • -Defined as bleeding arising below the ligament of Treitz (95% of cases arise from the colon)
    • -Less likely to have orthostasis than upper GI bleeds, or require transfusions
    • -Mortality is less than 3%
  7. What are the causes of Acute Lower GI Bleeds?
    • -Diverticulosis  -Vascular ectasias
    • -Neoplasms  -Inflammatory bowel disease
    • -Anorectal disease  -Ischemic colitis
  8. What is Diverticulosis?
    • -Most common cause of MAJOR GI bleeding (50%)
    • -Most diverticula are on left colon
    • -Most diverticular bleeding from right colon
    • -Presentation is acute, painless, large volume BRBPR
    • -Bleeding subsides spontaneously in 80%
    • -May rebleed in 25%
  9. What is Vascular Ectasias?
    • -Occurs throughout entire GI tract
    • -Painless
    • -5-10% of lower GI bleeds
    • -"Spider veins of the GI tract"
    • -Most common in >70 yo and in chronic renal failure
  10. What are Neoplasms? (lower GI bleeding)
    • -Benign polyps and carcinoma
    • -Usually chronic, occult blood loss
    • -10% of lower GI bleeds
    • -Apple core lesions
  11. What are some characteristics of Inflammatory Bowel (acute lower GI bleed)?
    • -Variable amounts of hematochezia
    • -Abdominal pain, tenesmus, and urgency are often present
    • -Crohn's disease
    • -Ulcerative colitis
  12. What is an anorectal disease? (acute lower GI bleed)
    • -Small amount of blood on toilet paper, or streaking stool
    • -Internal hemorrhoids cause painless bleeding
    • -Pain with BM suggests anal fissure
  13. What is Ischemic Colitis (acute lower GI bleed)?
    • -Most common in older patients, especially those with atherosclerotic disease
    • -In young patients, look for vasculitis, coag disorders, estrogen, long-distance runners
    • -Bleeding is usually mild and self-limited
  14. Name some other causes for acute lower GI bleeds.
    • -Radiation-induced proctitis
    • -Infectious colitis
    • -Solitary rectal ulcer
    • -Colonic varices
    • -Small bowel diverticula
  15. Acute Lower GI Bleed: Evaluation -> Color of stool

    What does blood-streaked stool suggest?
    -Distal lesion
  16. Acute Lower GI Bleed: Evaluation -> Color of stool

    What does a large volume of BRBPR suggest?
    -Colonic source
  17. Acute Lower GI Bleed: Evaluation -> Color of stool

    What does Maroon suggest?
    -right colon or small intestine
  18. Acute Lower GI Bleed: Evaluation -> Color of stool

    What does black (melena) suggest?
    -Above ligament of Treitz
  19. Acute Lower GI Bleed: Evaluation -> Color of stool

    What does 10% BRBPR suggest?
    -upper GI source (massive bleed)
  20. How would you exclude an upper GI bleed source?
    -NG tube
  21. With an acute lower GI bleed, if the patient is not anemic and less than 45 years old, then what would you perform?
    -Anoscopy and Sigmoidoscopy
  22. What would you perform to evaluate an acute lower GI bleed in a patient >45 or with anemia?
  23. What can be performed to localize an acute lower GI bleed?
    -Nuclear bleeding scans
  24. After unexplained, recurrent bleeds, how would you evaluate the small intestine as a source?
    -Enteroscopy/capsule imaging
  25. How are acute lower GI bleeds managed?
    • -Discontinue ASA and NSAIDs
    • -Therapeutic colonoscopy (can deliver epinephrine, cautery, or endoclips)
    • -Intra-arterial vasopressin or embolization
    • -Surgery for ongoing bleeding
  26. Less than _____ of blood loss may not cause any change in stool appearance.
    100 mL/d
  27. How is occult bleeding identified?
    -FOBT or FE deficiency anemia
  28. What are the causes of occult GI bleeding?
    • Neoplasms
    • Vascular abnormalities
    • Acid-peptic lesions (esophagitis, PUD)
    • Infections (nematodes, TB)
    • Medications (NSAIDs, ASA)
    • Inflammatory bowel disease
  29. If a patient is >40, has alarm symptoms, FH of GI cancer, or anemia disproportionate to menstrual loss, what tests should be performed?
    Colonoscopy or EGD
  30. What is the pathological accumulation of fluid in the peritoneal cavity?
  31. What conditions cause ascites associated with normal peritoneum?
    • Portal hypertension (>80% of patients)
    • Hypoalbuminemia
    • Salt & water retention by kidneys
    • Pancreatic, biliary, chylous, nephrogenic
  32. What conditions cause ascites associated with diseased peritoneum?
    • Infections (TB)
    • Malignancy
    • Inflammatory disorders
  33. What are the risk factors for liver disease?
    • ETOH
    • Transfusions
    • Needle use
    • History of viral hepatitis
    • History of cancer
    • Fever (bacterial peritonitis)
  34. What are the signs of ascites?
    • Jugular venous distension (JVD) (R-sided CHF) (Constrictive pericarditis)
    • Hepatomegaly: If tender, acute alcoholic hepatitis or Budd Chiari
    • Large abdominal wall veins (Cephalad flow indicates portal htn) (Inferior flow indicates hepatic vein obstruction)
    • Caput medusae
    • Chronic liver disease
    • Supraclavicular or periumbilical lymph nodes (malignancy)
    • Shifting dullness (1500mL)
  35. What are the signs of chronic liver disease?
    • Palmar erythema
    • Cutaneous spider angiomas
    • Gynecomastia
    • Dupuytren's contracture
  36. What establishes the presence of fluid with ascites?
    Abdominal ultrasound
  37. What establishes the cause of fluid in ascites?
    Abdominal paracentesis (Cell count, albumin and TP, culture and gram stain)
  38. What is the best single test to distinguish between portal hypertensive and non-portal hypertensive causes of ascites?
    Albumin and total protein (SAAG)
  39. If the serum-ascites albumin gradient is greater than 1.1 g/dL (high), what are the possible causes of ascites?
    • Cirrhosis
    • Chronic hepatic congestion
    • Nephrotic syndrome
    • Massive liver metastases
  40. If the serum-ascites albumin gradient is less than 1.1 g/dL (low), what are the possible causes of ascites?
    • Peritoneal carcinomatosis
    • Peritoneal TB
    • Nephrotic syndrome
  41. What condition shows: no apparent intra-abdominal source of infection, most patients have chronic liver disease
    Spontaneous bacterial peritonitis
  42. Why do patients with chronic liver disease get spontaneous bacterial peritonitis?
    • The ascites fluid is static
    • Fluid that doesn't move gets infected
  43. What are the signs and symptoms of spontaneous bacterial peritonitis?
    • Fever
    • Abdominal pain
    • Mental status changes
    • Worsening of renal function
  44. What is the most important diagnostic test for spontaneous bacterial peritonitis?
    Abdominal paracentesis