Chapter 16: GI Bleeding CS edits

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1.

AAA / aortoenteric fistula

suspected - if stable confirm
with

bedside US, CAT Scan

15.

Factors that increase

morbidity and mortality in
these patients

2.

_____________________accounts
for 50% of upper GI bleeding;

Peptic ulcer disease;

consider initiating protonpump inhibitor therapy

Hemodynamic instability,
ongoing symptoms, inability to
clear bleeding with lavage, age
of 60

16.

GI bleeds - more prominent

M/F?

males, elderly
(both upper and lower bleeds)

3.

Angiodysplasia Characterized by

painless bleeding that

may be mild or massive
occult blood in stools to
melena to hematochezia.

17.

Hemobilia - caused by

- trauma, hepatic tumors,

gallstones and parasites
- bleeding from the ampulla of
Vater; (upper GI bleed)

4.

Angiodysplasia most common in

patients older than 60 w/

history of cardiac or
renal disease

18.

history/risk factors;
ongoing hemorrhage

5.

Any elderly patient whose

complaints of abdominal pain are
out of proportion to examsuspect as what?

Mesenteric ischemia

Aortic fistula/history AAA repair

Esophageal varices
GI bleeds
Diverticulosis

19.

history to take

Barium enema used to study

lower GI bleed?

no; interfere with

endoscope & visceral
angiography

alcohol, NSAIDS, anticoags,

weight loss, stool caliber, AAA
repair, liver disease, abdominal
surgery

20.

in the presence of:

Portal HTN and coagulopathies

bright red clots in aspirate of NG

tube - indication for?

gentle gastric lavage

how can gastritis cause

bleeding (doesn't usually
on its own) ?

21.

every 4 hrs

C/C of Colitis
(whole section doesnt diff UC vs
Crohn's?)

abdominal cramps,
diarrheal stools containing
blood and mucopurulent
material, fever, weight
loss, anemia.

how frequent to check

hematocrit with active GI
bleed, after
hemostabilization?

22.

How to Dx hematochezia

Proctoscopy to visualize
hemorrhoids

23.

How to Dx Meckel's
Diverticulum?

Technetium scan or angiography

24.

If given permission, what

may you also do if
persistent GI bleeding is
present? in prep for
endoscope

-Place NG tube with increments

of 200-300 mL of either saline
or tap water
-Patient should be in LLD
position with the bed in reverse
Trendelenburg
-Lavage until the return is clear
-Adm of erythromycin IV will
stimulate gastric motility and
will also help to clear the
stomach of blood prior to
endoscopy

25.

if hematochezia from
UPPER GI source...

massive hemorrhage; mortality

26.

if melena associated with

LOWER GI source...

intestinal tract motility

decreased (over 14 hrs);
also pseudo-melena; pepto or
iron

27.

instructions for peptic

ulcer - avoid

smoking
alcohol
NSAIDS, aspirin
caffeine

28.

Is contrast media typically

used in patients with GI
bleed?

No. May obscure endoscopic

viscualization

6.

7.

8.

9.

C/C of patients with

diverticulosis

Cramping, lower abdominal

pain, LLQ tenderness.
May also have:
- tenesmus, constipation,
diarrhea

10.

Chief complaint of people with

anal fissures?

Painful bowel movements.

Will also see bright red
blood post-wiping

11.

Chief complaints of GI bleed

Hematemesis
hematochezia-bright red;
lower GI (sigmoid, rectum)
melena-tarry; upper GI
(stomach/duod)

12.

Colonic polyps

Painless rectal bleeding

and discovery of a polyp
on sigmoidoscopy,
colonoscopy, or barium
enema confirm the
diagnosis

13.

14.

Crohn's disease findings

differentiating colitis; ischemic

colitis rarely affects

Frank blood, abdominal

pain, anorexia, diarrhea,
weight loss, fatigue,
fistula formation, fissures,
hemorrhoids are common
rectum

29.

is initial hematocrit
always low?

no; often normal - until fluids

introduced shows dilution

30.

Lower GI bleed most

commonly the result
of what?

Diverticular disease;
then angiodysplasia, colonic ulcers

Mallory-Weiss
Syndrome

Tears in the esophageal mucosa and

submucosa that usually occur after
forceful retching and vomiting;
(alcohol* use usually factor)

32.

Mallory-Weiss
Syndrome also
reported following

chest compressions, coughing,

sneezing, BM straining

33.

meckel's
diverticulum

True diverticulum at umbilicus due to

persistence of vitelline duct. May
contain gastric acid-secreting tissue
leading to perforation.

34.

Meckel's
Diverticulum mc in

children under 2 yrs; rarely after 10 yrs

35.

meckel's
diverticulum pic

31.

36.

Meckel's
Diverticulum S&S

may mimic appendicitis

-Hemorrhage is most common
complication, also intestinal obstruction

MOA of somatostatin
/ octreotide

reduces splanchnic blood flow & GI

motility,
inhibits acid / secretions
(vasoconstrictor - inhibits GH, insulin,
glucagon)

38.

Most common cause

of esophageal
varices in the US

alcohol and viral cirrhosis;

(parasitic liver infestations -> cirrhosis
elsewhere)

39.

Most common cause

of hematochezia in
adults?

Hemorrhoids

Most likely causes

of lower GI bleed in
adolescent or young
adults?

meckel's diverticulum
IBD,
polyps

Most likely causes

of lower GI bleed in
adults over 60?

angiodysplasia
diverticula
neoplasms

37.

40.

41.

42.

Most likely causes of

lower GI bleed in adults
under 60?

diverticula
IBD
neoplasms

43.

percentage of pts which

upper or lower gi bleeds
stop?

most; 80-85% prior to ED arrival

-although can be intermittent,
can restart at any time

44.

Pharm treatment for peptic

ulcer ?

Omeprazole or rabeprazole;
somatostatin; octreotide

45.

The presence of
telangiectasias of the skin
and lips may indicate
which disease?

Osler-Weber-Rendu disease
(hereditary hemorrhagic
telangiectasia) - AD disorder!

46.

Rule out infectious colitis;

such as

shigella, campylobacter,
entamoeba histolytica, c. diff,
and salmonella

47.

Should GI bleed patients

receive anything by
mouth?

No

48.

Solitary Rectal Ulcer

Associated with

rectal prolapse
May result from straining at
stool. Patient passes blood and
mucus per rectum
-elderly and have chronic
constipation

49.

S/S of ongoing hemorrhage

Hematemesis or hematochezia
Hypotension, tachy, shock
(or Postural hypotension,
lightheadedness)

50.

Tenderness to palpation in
the epigastrium is common
with what 2 diseases?

Gastritis
Peptic ulcer disease

51.

Treating colitis

Surgery if severe. Medical

measures if mild-moderate

52.

Treating colonic polyps

Removal of polyps if bleeding

persists

53.

Treating Crohn's disease

Bowel rest, NG suction, IV

fluids. Surgery is rarely
indicated.

54.

Treating esophageal
varices

NG tube, Octreotide
Sclerotherapy, band ligation,
Sengstaken-Blakemore tube
tamponades hemorrhage

55.

Treating hemobilia

Embolization via interventional

radiographic technique

56.

Treating hemorrhoids

High fiber diet, stool softeners,

surgery if severe

57.

Treating Mallory-Weiss
Syndrome

Lavage until clear,

PPI or sucralfate to reduce
acid/bile

58.

treating Meckel's
Diverticulum

Hospitalize, surgery if severe

bleeding, intestinal obstruction,
diverticulitis, and umbilicoileal
fistulas

59.

Treating nonbleeding suspected

gastritis

GI cocktail"; Antacid with

lidocaine,
also: PPI, H2 antagonists

76.

What will suggest the presence of

Mallory-Weiss tears?

Vigorous retching or
vomiting prior to onset of
hematemesis

60.

Treating Rectal Ulcer

aid defecation. Avoid

surgery

77.

What will you hear on

auscultation in upper GI bleed?

61.

Treatment of angiodysplasia

Electrocoagulation,
embolization through
angiography

Hyperactive bowel
sounds (the blood
stimulates peristalsis)

78.

When should patients get

intubated?

Massive hematemesis or
S/S of shock

79.

When should rule out duodenal

source of bleeding?
????

If gastric lavage contents

reveal bile

80.

When should transfusion be

considered?

Persistent hypotension
despite infusion of 2 L of
crystalloid

81.

When should you obtain

orthostatic blood measurements?

If initial SBP is >100 and

pulse <100 in supine
position

82.

Where are most of the bleeds

going to be at in these patients?

Upper GI (proximal to the

ligament of Treitz)

83.

Where is the pain located in

peptic ulcer disease patients?
What type of pain is it described
as?

LUQ;
burning pain - 40% of
bleeding pts may not
have pain prior to onset
of bleed

84.

Which fluids are needed for

possible fluid resuscitation?

Warmed lactated Ringer's

or normal saline

85.

Which labs should you order to

assess tissue perfusion status?

Venous blood gas

Lactate

86.

Which patients need an ECG with

GI bleed?

50 y/o or older; anemia

Hx of IHD
Chest pain, SOB, severe
hypotension

87.

Which patients should you

monitor urinary output with foley
catheter?

Shock or
Hx of cardiac or renal
dysfunction

88.

Which type of sarcoma is

associated with cutaneous
lesions?

Visceral kaposi sarcoma

62.

Treatment of diverticulosis

Get a colonoscopy to
visualize area, may need
surgery if massive bleeding,
selective angiography with
embolization is also an
option for bleeding

Upper GI bleeding in the

presence of an abdominal
aortic aneurysm should be
assumed to be secondary to an
___________ __________ until
proven otherwise

Aortoenteric fistula

64.

What are patients at risk for

who have hematemesis or
hematochezia?

Exsanguination

65.

What can over vigorous lavage

cause?

Gastric erosions

66.

What does persistent bleeding

during NG lavage indicate?

Potential life-threatening
upper GI bleed.
-Refer to GI
specialist/surgeon

63.

67.

What exam should you do (if no

shock is present)?

Gastric lavage
rectal exam

68.

What is gastritis commonly

associated with?

alcohol
ASA, NSAIDS
caffeine

69.

What is hematochezia due to?

blood in stool; not

digested...
Bleeding distal to ligament
of Treitz.

70.

What is the most accurate

diagnostic tool or upper GI
bleeds?

Endoscopy

71.

what level of hematocrit

consider early transfusion?

<30%

72.

what may be elevated in pts

with upper Gi bleed

BUN

73.

What may hematuria indicate in

patient with GI bleed?

Abdominal aneurysm

74.

What may the bleeding be

related to in
immunocompromised patients?

Kaposi sarcoma,
lymphoma, cytomegalovirus
ulcerations

75.

What other cardiac condition

should you be weary of in
patients with GI bleeds?

MI. Often present without

chest pain