Ugib : Upper Gi Bleeding / Up To Date

Front 1

UGIB

presentation

Back 1

1-hematamesis

2-melena

Front 2

hematamesis

Back 2

vomitting of blood or coffee-ground material

Front 3

melena

Back 3

black tarry stool

Front 4

UGIB

initial assessment

Back 4

1-hemodynamic status assessment

2-resusctation

3-cause / investigation

4-ttt

Front 5

initial evaluation / steps

UGIB

Back 5

-history

-physical exam

-labs

-NG lavage in some cases

Front 6

UGIB

goals of assessment

Back 6

-assess bleeding severity

-identify potential source

Front 7

UGIB

si / sx / PEx : that goes with UGIB ((suggestive))

Back 7

-hx of melena

-melena at stool exam

-NG Tube lavage : coffe-ground/blood

-BUN/Cr ratio > 30

-

Front 8

UGIB

factors that suggest severe bleeding

Back 8

-red blood during NG Tube lavage

-tachycardia

-Hb level < 8 g/dl

Front 9

UGIB

definition ??

Back 9

bleeding proximal to the ligament of trietz

Front 10

UGIB

coffee ground vs fresh blood ? significance ?

Back 10

coffee-ground suggest limited bleeding

frankly bloody emesis suggests moderate-severe ongoing bleeding

Front 11

melena

source of bleeding

Back 11

90 % prox to ligament of treitz

10% : small bowel + prox. colon

Front 12

melena amount of bleedeing to be seen

Back 12

as little as 50 ml

Front 13

hematochezia

what ??

source ??

Back 13

red-maroon blood in stool

usually LGIB

may due to massive upper GIB

Front 14

how to exclude upper causes of LGIB

Back 14

if pt is hemodynamically stable it's unlikely to be due to upper causes

Front 15

DDx of UGIB

Back 15

-PUD

-varices

-portal hypertensive gastropathy

-angiodysplasia

-malignancy

-marginal ulcer

-aortoenteric fistula

Front 16

liver disease hx

causes of UGIB

Back 16

-varices

-portal hypertensive gastropathy

Front 17

scenario #1 :

pt with UGIB and murmur ??

Back 17

angiodysplagia + aortic stenosis

Front 18

clues that suggest angiodysplagia

Back 18

-renal diseases

-aortic stenosis

-hereditary hrgcic talengiactasia

Front 19

marginal ulcer ??

Back 19

ulcer at anastomosis site (gastroenteric anastomosis)

Front 20

how comorbidities affect GIB ??

Back 20

-cardiac/resp : low transfusion threshold

rate of rescusitation / transfusion

-renal : fluid / blood transfusion

-coagulopathy/ low plt : may need FFP / plt

-dementia : may need intubation for risk of aspiration

-

Front 21

important points in drug hx ??

Back 21

1-drugs increase risk of PU

2- drugs increasing risk of pills esophagitis

3-drugs increasing risk of bleeding : anti-plt / anti-coagulant

4-drugs may alter the color of stool

Front 22

drugs that change stool color to black ?

Back 22

-bisthmus

-iron

Front 23

hx in UGIB ??

Back 23

1-things that suggest a possible cause

2-things that suggest severity

Front 24

history in UGIB

to suggest severity ?

Back 24

orthostatic dizziness

confusion

angina

severe palpitation

cold / clammy extremities

Front 25

history in UGIB

past history suggest a possible cause

Back 25

-prior episodes

-history of liver D

-history of alcohol

-AAA / aoric graft

-renal disease

-aortic stenosis

-hereditary hrgic talengiactasia

-H.Pylori / PUD

-NSAIDs use

-smoking

-previous gastric surgeries

-comorbidities

Front 26

history of UGIB

possible causes suggested by symptomes

Back 26

-epigastric / RUQ pain : PUD

-odynophagia / GERD / dysphagia : esophageal ulcer

-emesis / retching / coughing prior to : mallory-weiss

-juindice / weakness / fatuige / anorexia / abdominal distention : variceal

-dysphagia / early satiety , wt loss , cachexia : malignancy

Front 27

physical exam

Blood pressure changes

Back 27

-resting tachycardia no hypotension : mild-moder hypovolemia

-orthostatic hypotension

-supine hypotension

Front 28

resting tachcardia is suggestive of ?

Back 28

mild - moderate hypovolemia

Front 29

orthostatic hypotension indicating blood loss of??

Back 29

15 %

Front 30

what do we mean by orthostatic hypotension ??

Back 30

systolic BP drop >= 20 mmHg

pulse increased by 20 bpm

represent 15 % of volume loss

Front 31

supine hypotension represent .......% blood loss ??

Back 31

40 %

Front 32

why to put NG tube ??

Back 32

if doubt about UGI as source of bleeding

looking if active bleeding or not

may facilitate endoscopy by removing particles

Front 33

when to think of perforation ?

Back 33

severe abd. pain withrebound tenderness

Front 34

lab tests in UGIB ??

Back 34

-CBC

-chemistry

-LFT

-PT / PTT / INR

-seria ECG / cardiac enzymes in pt at cardiac risk

Front 35

when pt Hb is truly representative of his Hb ??

Back 35

at 24 hrs

by this time influx of extravascular fluid and rescusitation

Front 36

causes of falsely low HB ???

Back 36

ovr-hydration

Front 37

Hb monitoring should be Q......?

Back 37

Q2 hrs >>>>>Q8hrs

depending upon severity

Front 38

MCV / Blood film / RBCs in GI bleeding ??

Back 38

normochromic : if acute

microcytic : if chronic

Front 39

clue for upper GI bleeding in KFT ??

Back 39

BUN : Cr ratio > 20 :1

urea : cr ratio > 100 :1

__________________________________________-

the higher the ratio the more likely to be secondary UGI source

Front 40

indications for ICU admission in UGIB ??

Back 40

1-unstable pt (hypotensive / postural hypo))

2-active bleeding evident by hematamesis / bright red blood by NG or hematochezia

Front 41

vitals monioring in UGIB ??

Back 41

ALL unless low-risk should be on continious monitoring

Front 42

manegment steps

Back 42

1-general support

2-fluid resuscitation

3-blood transfusion

4-medications

5-consultations

6-diagnostic tests

7-risk stratification

Front 43

general support measures ??

Back 43

1-O2 by nasal cannula

2-NPO

3-Two large pores cannulas 16 or larger

4-central line and CVP if unstable/close monitoring

5-intubation if aspiration risk (confusion / active bleeding))

Front 44

initial resuscitation fluid

type

amount

rate

Back 44

NS or ringer

500 ml

over 30 min

Front 45

blood transfusion

indications

Back 45

1- any pt < 7

2- cardiac pt with hb < 9

___________________________

any pt with active bleeding + hypovolemia even with normal hb

Front 46

pt who need low transfusion threshold

Back 46

1-massive bleeding

2-cardiac

-symptomatic periphral vascular D

-stroke / TIA

-recent transfusion / surgery / trauma

Front 47

pt who you must to avoid un-necessary transfusion

higher threshold

Back 47

variceal bleeding

increased bleeding risk with transfusion

Front 48

indications to give FFP with active bleeding ??

Back 48

INR > 1.5

after each 4 units of PRBCs

Front 49

indication to give plt with active UGIB ??

Back 49

< 50.000

or life-threatining bleeding who are anticoagulated \; clopidogrel / asa

Front 50

is prolonged INR is a contraindication for endoscopy

Back 50

mild - moderate is not

try to decrease INR > 3 before

Front 51

medications used in UGIB ?

Back 51

-acid supression

-prokinetics

-somatostatins

-Abx with cirrhosis

-tranexamic acid

Front 52

use of acid supression ??

PPI or H2

Back 52

use IV PPI twice daily till endoscopy done and cause known

PPI decreases rebleeding ........ but H2 not

Front 53

benefit of acid supression by PPI ??

Back 53

-dcreases rebleeding risk

-decreases hospital stay

-decreases blood transfusion