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21 Cards in this Set
- Front
- Back
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Upper (UGI) and Lower (LGI) bleeds
- age association? - do the majority get transfusions? |
- LGI is almost all elderly; UGI is much more common in the elderly
- yes |
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Melena (Black, tarry stool) is usually associated with a bleed where?
Hematochezia (bloody stool; red or maroon)? What is orthostasis a sign of? |
- upper source
- lower, but could be upper + rapid transit time Hypovolemia |
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___% of UGI are self limited and require only supportive tx.
Does variceal bleeding have a higher mortality rate than UGI bleeding from other causes? |
80%
yes |
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"Coffee-ground" emesis is usually associated with which type of bleed?
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UGI
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Do barium studies play a role in the the eval of acute upper GI bleeds?
- what imaging is used? |
No, barium will just get in the way when we go down w/ an endoscope.
- NG Aspirate (don't do this if you're just going to go ahead with an endoscopy) - Upper Endoscopy - occasionally Arteriography |
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What kind of tx can the endoscope be used to admin in an acute upper GI bleed?
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- Injection of bleeding site with epinephrine, saline, alcohol
- Application of heat to bleeding site: heater probe, laser - Endoscopic clipping of bleeding site - Banding or sclerosis of varices |
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Older age
Shock/hemodynamic instability/orthostasis Comorbid disease states (e.g., coronary artery disease, congestive heart failure, renal and hepatic diseases, cancer) Specific endoscopic diagnosis (e.g., GI malignancy) Use of anticoagulants/coagulopathy Presence of a high-risk lesion (ulcer) ... all these put a pt with an GI bleed at risk of what? What are some of the high-risk lesions (ulcers)? |
rebleed
arterial bleeding; nonbleeding visible vessel clot |
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Does endoscopic tx effectively reduce rebleeding?
- need for surg? - mortality? |
yes, yes, yes.
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What pharmacologic tx's are available for UGI bleed tx? (2)
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IV PPI --> clot stabilization: @ph6 pepsin can't work and lyse clots
IV octreotide to decrase portal pressure for variceal bleeding. |
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What portal pressures (in mmHg) are typically required to develop varices?
- what is the best predictor of variceal hemorrhage? - what is the mortality of the first, massive bleed? |
>12mmHg
- size of varix - 30-50% |
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Why is the esophageal mucosa and the rectal mucosa especially vulnerable to varicies?
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Esophageal:
- because the branches of the portal system join the systemic Rectal: - systemic joins the portal circ. |
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Banding or sclerosis
Balloon tamponade Pharmacologic decrease in portal pressure with octreotide (older studies used vasopressin/nitroglycerin combination) shunting of portal blood to systemic circulation: TIPS or surgical shunt ...all of these are tx for what? |
Variceal Hemorrhage
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Do most LGI bleeds occur acutely and require hospitalization?
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No. most are slow, w/ 25% chance of recurrence.
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DIverticulosis: outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall.
- are diverticular bleeds usually large volume? |
yes.
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What are some of the criteria for colonoscopy in pt with suspected LGI bleed?
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Active colonic bleeding site
Non-bleeding visible vessel Adherent clot Fresh blood localized to a colonic segment Ulceration of a diverticulum with fresh blood in the immediate area Absence of fresh blood in the terminal ileum with fresh blood in the colon |
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What is the most sensitive test to detect a LGI bleed? Most specific?
Why isn't colonoscopy just used for all of it? |
Bleeding scan
Angiography, but requires more of a blood loss. difficult in an unprepped pt. |
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How does a bleeding scan work?
If it is positive, what usually follows? Range of bleeds that a bleeding scan can pick up? Angiography? |
uses radiolabeled blood (nuclear medicine)
angiography (as low as) 0.1-0.5 mL/min 0.5-1.0 mL/min |
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What is occult GI blood loss?
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Bleeding site not identified on upper or lower endoscopy
May be intermittent bleed from small lesion ei: Dieulafoy lesion Small bowel source of bleeding arteriovenous malformation, malignancy, NSAID ulcers, Crohn’s disease, other inflammatory conditions of small intestine |
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What are indications for the capsule endoscopy?
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- occult GI blood loss
- suspected Crohn's dz - certain polyposis syndromes screening |
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What is the first, most important step in acute GI bleeding tx?
Should a hemeoccult be used in an acute setting? |
Stabilization
No; ONLY use for take-home screening of colon cancer. |
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Why is the single balloon enteroscopy so useful?
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can "pull" the scope along, get deeper than ever before.
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