Gi Bleeding

Front 1

206. Significance of red blood in stool?

Back 1

a. Usually indicates lower G.I. Bleeding.
b. In about 10% of cases, extremely brisk/rapid or high–volume upper G.I. Bleeding leads to red blood from the rectum.

Front 2

207. Black stool significance?

Back 2

a. Indicates upper G.I. Bleeding, which is usually defined as that occurring proximal to the ligament of treitz/demarcation between the duodenum and the jejunum.
b. Black stool usually results from at least 100 ML of blood loss.

Front 3

208. Heme–positive brown stool?

Back 3

This can occur from as little as 5 to 10 ML of blood loss.

Front 4

209. Coffee ground emesis?

Back 4

Needs very little, gastric, esophageal, or duodenal blood loss– as little as 5– 10 ml.

Front 5

210. The 74–year–old man with a history of aortic stenosis comes to the ED, having had five red/black bowel movements over the last day. His pulse is 112, blood pressure 96/64. What is the next best step in management?
a. Colonoscopy
b. consult gastroenterology
c. CBC
d. bolus of normal saline
e. transferred to the ICU.

Back 5

Answer: D – bolus of normal saline.
The most urgent step in severe G.I. Bleeding is fluid resuscitation.
When the systolic blood pressure is low, or the pulse is while high, there is been at least a 30% volume loss.
Step 3 does not allow you to order specific doses; hence, or you can order as a bolus.

Front 6

211. What is the most important thing to do in an acute G.I. Bleed?

Back 6

Determine the hemodynamic stability?

Front 7

212. Orthostatic Hypotension?

Back 7

a. A drop in systolic pressure of > 20 mmHg
or
b. A rise in pulse of 10 bpm.

Front 8

213. CCS tip: with large volume, G.I. Bleeding, what should you order?

Back 8

1. Bolus of normal saline or ringers lactate
2. CBC
3. PT/INR
4. type and cross
5. G.I. Consult
6. EKG

Front 9

214. When do I transfuse packed red blood cells in older person?

Back 9

Hematocrit <30

Front 10

215. When do I transfuse pRBCs in a younger patient w/no heart disease?

Back 10

Hematocrit < 20–25.

Front 11

216. when do I transfuse fresh frozen plasma?

Back 11

When there is elevated PT/INR and vitamin K is too slow.

Front 12

217. When do I transfuse platelets?

Back 12

If the patient is bleeding or to undergo surgery, transfuse platelets when they are <50,000.

Front 13

218. what is the most common cause of death in G.I. Bleeding?

Back 13

a. Myocardial ischemia.
b. This is why he should get an EKG in older patients with severe G.I. Bleeding.
c. The the myocytes of the left ventricle cannot distinguish between ischemia, anemia, Carmen monoxide poisoning, and coronary artery stenosis.
d. All of these lead to myocardial infarction.

Front 14

219. When is nasogastric choose the answer?

Back 14

In place and NG tube in the occasional patient when you are unsure whether bleeding is from an upper or lower G.I. Source. The nasogastric tube has no therapeutic benefit; it will not stop bleeding.
Iced saline lavage is worthless and is always wrong.

Front 15

220. Treatment of G.I. Bleeding?

Back 15

a. First: fluid resuscitation.
b. The most important measures of severity are the pulse and blood pressure.
c. If the pulse is elevated or the blood pressure is decreased, you can always give more fluid.
d. If you must give so much fluid to maintain blood pressure that the patient becomes hypoxic, then give the fluid and increase oxygenation, even if it means in intubating the patient.
e. Hypotension supersedes all other therapeutic priorities.
f. Fluid resuscitation is more important than determining the specific etiology of the source of bleeding.

Front 16

221. How to manage pt. with GI bleeding?

Back 16

Correcting anemia, thrombocytopenia, or coagulopathy is more important than endoscopy.
If the platelets are low, and giving platelets is more important than consulting G.I. Or moving the patient to the ICU.

Front 17

222. What percent of G.I. Bleeding stops with adequate fluid resuscitation even without endoscopy?

Back 17

80%.
If you scope the patient but do not correct the anemia, thrombocytopneia, or elevated PT/INR, the bleeding will NOT stop.
Fluid resuscitation BEATS scoping!

Front 18

223. Tx of GI bleeding + ulcer disease?

Back 18

Add a PPI to the initial resuscitation of fluids, blood, platelets, and plasma.

Front 19

224. Presentation of variceal bleeding?

Back 19

Look for an alocholic w/hematemesis and/or liver disease (cirrhosis).The other gluces to the presnce of esophageal varices are the presence of splenomegaly, low platelets, and spider angiomata or gynecomastia.

Front 20

225. Treatment of variceal bleed?

Back 20

a. Add octreotide to the initial orders.

If above does not work:
b. Upper endoscopy–For banding of the varices or sclerotherapy.

Front 21

226. MOA of octreotide for esophageal bleed?

Back 21

a. Somatostatin analogue
b. It decreases portal HTN.

Front 22

227. What should be done with bleeding persists w/moving the clock forward?

Back 22

a. TIPS procedure (Transjugular intra–hepatic portosystemic shunts (TIPS).
b. This is using a catheter to place a shunt between the portal vein and hepatic vein.
c. This essentially replaces the need for surgical shunt placement.

Front 23

228. What is the most common complication of a TIPS procedure?

Back 23

Hepatic encephalopathy.

Front 24

Tx. used in the long-term management of portal hypertension to decrease the frequency of bleeding.

Back 24

Propranolol.

Front 25

229. Blakemore gastric tamponade balloon?

Back 25

a. This procedure will TEMPORARILY stop bleeding from varices.
b. It is rarely performed and is only a temporary measure to stop bleeding to allow a shunt to be placed.

Front 26

230. Sources of bleeding in the upper GI can have the following 4 causes?

Back 26

1. Ulcer disease
2. Esophagitis, gastritis, duodenitis
3. Varices
4. Cancer

Front 27

231. 6 causes of bleeding in the lower GI?

Back 27

1. Angiodysplasia
2. Diverticular disease
3. Polyps
4. Ischemic colitis
5. IBD
6. Cancer

Front 28

232. When should you use a Technetium bleeding scan “tagged red cell scan”?

Back 28

This test is performed to detect the site of bleeding IF endoscopy does not reveal the souce. It will let you know the location but the the exact cause.

Front 29

233. Utility of angiography for GI bleed?

Back 29

Tells you the PRECISE vessel that is bleeding.
b. It can be done preoperatively in massive GI bleeding to let you know which part of the colon to resect.

Front 30

234. Utility of capsule endoscopy?

Back 30

a. Detects the location of the GI bleeding from the SMALL Bowel, IF upper an dlower endoscopies do not reveal the answer.
b. It gives an enormous quantity of pictures but does not allow a biopsy or therapeutic intervention such as you can do with endoscopy.

Front 31

235. Risk of unncessary stress ulcer prophylaxis with PPIs?

Back 31

Increases the risk of pneumonia and C. diff.

Front 32

236. Cause of Acute mesenteric ischemia?

Back 32

Embolus from heart.

Front 33

Mesenteric ischemia with embolus from heart clinical presentation.

Back 33

a. Sudden onset of extremely severe abdominal pain
and
b. possible bleading.
c. Physical exam shows a relatively benign abdomen.
d. Look for an older patient with a history of valvular heart disease, and the very sudden onset of pain.

Front 34

238. Diagnostic testing for acute mesenteric ischemia?

Back 34

a. Metabolic acidosis (elevated lactate level)
b. elevated amylase level

Front 35

239. what is the most accurate test for acute mesenteric ischemia?

Back 35

Angiography.

Front 36

240. Treatment of acute mesenteric ischemia?

Back 36

a. Surgical resection of the bowel.
b. Very ill patients should go straight to the operating room for surgical resection.
c. This is a surgical emergenc
d. If left undetected and untreated, the patient will die quickly.