Medicine 06 Upper And Lower Gastrointestinal Bleeding

Front 1

What information is important when taking a history for GI bleeding? (5)

Back 1

1. Duration of bleeding (acute versus chronic)
2. Presence of abdominal pain, dysphagia, dyspepsia, nausea and vomiting, change in bowel habits, weight loss, anorexia, weakness, fatigue, dizziness, and easy bruisability
3. Past medical history of PUD or bleeding episodes, cirrhosis (previous varices or portal gastropathy), inherited coagulopathy, or aortic bypass graft (as a result of risk of aortoenteric fistula)
4. Use of certain medications, including acetylsalicylic acid, NSAIDs, warfarin, and heparin
5. Social history of alcohol and tobacco use

Front 2

What are symptoms and signs of GI bleeding?

Back 2

Depends on the source and severity of the bleed, and on any coexistent diseases

Front 3

What are symptoms and signs of acute, severe GI bleeding?

Back 3

Hemodynamic instability (i.e., tachycardia, tachypnea, orthostatic hypotension, angina, mental status change or coma, and cold extremities)

Front 4

What are symptoms and signs of chronic GI blood loss?

Back 4

Signs of anemia (e.g., weakness, fatigue, pallor, angina, and dizziness)

Front 5

What additional signs may be present in a cirrhotic patient with GI bleeding?

Back 5

Hepatic encephalopathy or HRS. Look for stigmata of chronic liver disease—spider angiomata, palmar erythema, gynecomastia, testicular atrophy, Dupuytren's contractures, and decreased muscle bulk.

Front 6

What are the more common causes of UGI bleeding?

Back 6

Peptic ulcer, hemorrhagic gastritis, Mallory-Weiss tear, erosive esophagitis, varices, neoplasm, aortoenteric fistula, and hemobilia › Remember UVA MED
› Ulcers (PUD)
› Varices
› AVMs
› Mallory-Weiss tear, malignancies
› Erosions (stress gastritis), esophagitis
› Dieulafoy's lesion

Front 7

What are the more common causes of LGI bleeding?

Back 7

Hemorrhoids and fissures (rarely require hospitalization), AVMs, diverticulosis, ischemia, neoplasms, IBD, infectious colitis, radiation colitis, and Meckel's diverticulum › Remember NADIR
› Neoplasia
› AVMs
› Diverticulosis
› IBD or Infectious colitis or Ischemia
› 'Rhoids (hemorrhoids)

Front 8

What are the most common causes of LGI bleeding in the following patients? › Patients >60 years of age

Back 8

Diverticulosis, ischemic bowel, AVMs, and carcinoma

Front 9

What are the most common causes of LGI bleeding in the following patients? › Young patients

Back 9

Hemorrhoids, fissures, colonic polyps, IBD, and infectious colitis

Front 10

What is the workup for GI bleeding?

Back 10

The patient must be stabilized before a diagnostic workup is started. Depending on the clinical presentation, the workup may include NG aspiration, rectal examination, endoscopy, radionuclide imaging, selective arteriography, and barium studies.

Front 11

Is NG aspiration necessary in LGI bleeding?

Back 11

In all patients with GI bleeding, NG aspiration and lavage should be considered. 10–15% of patients presenting with hematochezia will have UGI sources, which may be identified by performing NG aspirate. It is important to obtain bile-tinged secretions, as this helps to exclude bleeding sources proximal to the ligament of Treitz.

Front 12

How is NG aspiration helpful?

Back 12

• It is helpful in localizing the bleeding source and determining the rate of blood loss. Continuous, bright red blood demonstrates active, vigorous bleeding, whereas "coffee grounds" are more consistent with bleeding that is slower or has stopped.
• Note: There is a 16% false-negative rate for NG lavage (even if bile is visualized) in patients with endoscopically active UGI bleeding.

Front 13

Is a rectal examination needed for UGI bleeding?

Back 13

Yes, in any patient with GI bleeding (even apparently obvious UGI bleeding). Character and color of stool can help determine the severity and source of bleeding.

Front 14

How is upper endoscopy helpful?

Back 14

EGD is the best tool for diagnosing and potentially treating a UGI bleed.

Front 15

When is proctosigmoidoscopy or colonoscopy used?

Back 15

When evaluating LGI bleeding, unless active bleeding precludes visualization

Front 16

What are other endoscopic procedures used to evaluate GI bleeding?

Back 16

Enteroscopy, which evaluates the proximal small bowel. ERCP may be used if a biliary or pancreatic source is suspected. Capsule endoscopy may be useful when traditional forms of endoscopy fail to reveal a bleeding source, particularly if the small bowel is involved.

Front 17

What procedures are possible with endoscopy?

Back 17

Thermal coagulation, injection of epinephrine, ethanol, and sclerosing agents, variceal band ligation, laser or argon plasma coagulation, and application of blood-clotting agents or tissue adhesives

Front 18

How is radionuclide scanning used?

Back 18

Nuclear medicine labeling of red blood cells may reveal the approximate site of bleeding.

Front 19

What bleeding rate allows nuclear scans to detect active bleeding?

Back 19

As low as 0.1 mL/min. A positive scan may localize the source of bleeding and assist in directing therapeutic procedures.

Front 20

How much bleeding allows selective arteriography to localize the source?

Back 20

At least 0.5–1.0 mL/min. Arteriography is less sensitive than a nuclear medicine bleeding scan, but is more precise at localizing the bleeding site.

Front 21

What interventional radiologic procedures are used to control or treat GI bleeding?

Back 21

Embolization of bleeding vessels with gel foam or coils, injection of vasopressin, and TIPS for variceal bleeding

Front 22

Are barium studies helpful to detect bleeding?

Back 22

Not recommended in the acute setting, because they provide a much lower diagnostic yield than any of the above tests, and can hinder endoscopy and render arteriography uninterpretable. Barium studies, such as small bowel follow-through or enteroclysis, may be useful in evaluating the portion of small bowel that cannot be reached endoscopically.

Front 23

What laboratory tests are needed?

Back 23

1. CBC, PT, PTT, and blood type and screen
2. Electrolytes, glucose, and BUN are very important; elevated BUN may occur in up to 75% of patients with acute UGI bleeding as a result of digestion of blood proteins and absorption of nitrogenous compounds in the small intestine.
3. Consider an arterial blood gas, liver function tests, amylase, and cardiac enzymes, depending on clinical scenario.
4. Serial hemoglobin and hematocrit

Front 24

What is the treatment for GI bleeding?

Back 24

Stability of the patient dictates course of action.

Front 25

What is the treatment for hemodynamic instability in patients with GI bleeding?

Back 25

Admit to the intensive care unit, obtain large-bore intravenous access, and commence with vigorous crystalloid or colloidal resuscitation. Frequent monitoring of vital signs and urine output is essential.

Front 26

What is important to keep in mind when transfusing blood or blood products?

Back 26

Blood transfusions can lower serum calcium if citrate is used in the stored blood. Thus, consider giving 1 ampule of calcium gluconate intravenously for every 3–4 units of transfused blood. Platelets and clotting factors may also be diluted (give platelets and fresh-frozen plasma as needed).

Front 27

What is the treatment of a coagulopathy in patients with GI bleeding?

Back 27

Fresh-frozen plasma or vitamin K for abnormal coagulation variables (i.e., PT, PTT), platelets for thrombocytopenia or dysfunctional platelets. Recombinant factor VII may be beneficial in coagulopathy as a result of liver disease.

Front 28

When bleeding is caused by PUD, what are the endoscopic findings (i.e., stigmata) that help to predict the risk of rebleeding (in the absence of endoscopic therapy)?

Back 28

Clean-based ulcers, ulcers with pigmented spots, adherent clots, nonbleeding visible vessel, and active bleeding

Front 29

Without endoscopic therapy, what is the rebleeding rate associated with these stigmata?

Back 29

• Clean-based ulcer, 5%
• Flat pigmented spot in ulcer base, 10%
• Ulcer with adherent clot, 20%
• Ulcer with nonbleeding visible vessel, 40%
• Actively bleeding ulcer, 55%

Front 30

What is the treatment for bleeding associated with PUD?

Back 30

• Medical therapy includes supportive care, transfusions when needed, correction of any coagulopathy, and acid suppression (with PPIs or H2RAs).
• For intermediate- and high-risk lesions, endoscopic thermal coagulation, with or without preceding epinephrine injections, is frequently performed.

Front 31

What is the medical treatment for acute esophageal varices that are causing GI bleeding?

Back 31

• Intravenous octreotide is used to "decompress" the portal venous system without the significant cardiovascular side effects of vasopressin and nitroglycerin.
• Broad-spectrum antibiotics are indicated, as there is increased morbidity and mortality directly attributable to infectious complications of variceal bleeding in a cirrhotic patient.

Front 32

What four procedures can be used to treat acute esophageal varices?

Back 32

• Endoscopic variceal band ligation (or sclerotherapy) is usually the initial choice of definitive treatment.
• A Sengstaken-Blakemore tube may be used as a temporary measure (usually not exceeding 48 hours); it works by compressing gastroesophageal varices by balloon tamponade. It should only be used by experienced physicians, because serious complications can occur, including perforation, airway occlusion, aspiration, and ischemic necrosis of gastric or esophageal tissue.
• TIPS may be needed for acute variceal bleeding that is refractory to endoscopic therapy, or for recurrent episodes of variceal bleeding despite attempts at endoscopic management.
• Surgery with portacaval shunt or esophageal transection, more commonly used in the past, may rarely be required.

Front 33

What is a TIPS procedure?

Back 33

Transjugular, intrahepatic portosystemic shunt

Front 34

What oral medications may decrease the risk of variceal bleeding?

Back 34

Beta-Adrenergic blockers. Nitrates are sometimes used.

Front 35

Are gastric varices treated the same as esophageal varices?

Back 35

Unlike esophageal varices, gastric varices do not respond optimally to band ligation; novel therapies for gastric varices, such as the injection of various gluelike materials into the varices, are being investigated.

Front 36

How are antisecretory agents—H2 antagonists, PPIs, and antacids—useful in GI bleeding?

Back 36

They neutralize pathogenic gastric acid after UGI bleeding. Maintaining intragastric pH >4.0 reduces the direct harmful effects of acid and pepsin on the bleeding lesion and allows platelets to aggregate.

Front 37

What is the role of surgery in GI bleeding?

Back 37

Acute bleeding frequently stops, either spontaneously or after endoscopic therapy. However, some bleeding lesions are associated with a high risk of rebleeding within the first 72 hours. 15% of such patients with GI bleeding require surgery because bleeding continues despite medical, endoscopic, or radiographic therapeutic measures.

Front 38

What are the prognostic factors for GI bleeding?

Back 38

• Severe persistent bleeding (e.g., variceal or arterial bleeding from an ulcer) is associated with a higher mortality.
• Onset of bleeding after admission or rebleeding in the hospital carries a mortality of at least 30% in some series.
• The mortality rate from GI bleeding doubles in patients older than 60 years of age and in patients with concomitant central nervous system, hepatic, pulmonary, or neoplastic disease. It triples in patients with renal disease, and it increases several-fold in patients with cardiac or pulmonary disease.
• Urgent surgery for UGI bleeding is associated with a 25% mortality (versus a 2% rate associated with elective surgery).

Front 39

What is the mortality of GI bleeding?

Back 39

The 5–10% overall mortality rate associated with acute GI bleeding has not changed despite improved diagnostic, endoscopic, surgical, and intensive monitoring capabilities.