Podcast
Questions and Answers
Which of the following is the most effective pharmacological treatment for esophageal varices?
Which of the following is the most effective pharmacological treatment for esophageal varices?
What is the purpose of the Sengstaken-Blakemore tube?
What is the purpose of the Sengstaken-Blakemore tube?
Which endoscopic procedure is specifically therapeutic for achieving hemostasis in upper gastrointestinal bleeding?
Which endoscopic procedure is specifically therapeutic for achieving hemostasis in upper gastrointestinal bleeding?
What is the most common source of upper GI bleeds?
What is the most common source of upper GI bleeds?
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Which of the following complications can arise from using a Sengstaken-Blakemore tube?
Which of the following complications can arise from using a Sengstaken-Blakemore tube?
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Which of the following is NOT considered a risk factor for gastrointestinal bleeding?
Which of the following is NOT considered a risk factor for gastrointestinal bleeding?
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Which condition is most likely to rebleed among upper GI sources?
Which condition is most likely to rebleed among upper GI sources?
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What should not serve as a reassurance for a clinician assessing a patient with potential gastrointestinal bleeding?
What should not serve as a reassurance for a clinician assessing a patient with potential gastrointestinal bleeding?
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Where is the ligament of Treitz located in relation to upper and lower GI bleeds?
Where is the ligament of Treitz located in relation to upper and lower GI bleeds?
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Which of the following conditions is the most common cause of lower GI bleed?
Which of the following conditions is the most common cause of lower GI bleed?
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Which symptom suggests a lower GI bleed?
Which symptom suggests a lower GI bleed?
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What initial lab test should be performed immediately for a significant GI bleed?
What initial lab test should be performed immediately for a significant GI bleed?
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What finding on physical examination might suggest underlying coagulopathy?
What finding on physical examination might suggest underlying coagulopathy?
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Which of the following is not a useful immediate imaging study for an acute GI bleed?
Which of the following is not a useful immediate imaging study for an acute GI bleed?
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In the management of an acute GI bleed, which of the following fluids is typically administered first?
In the management of an acute GI bleed, which of the following fluids is typically administered first?
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Which medication class is commonly used to manage GI bleeding?
Which medication class is commonly used to manage GI bleeding?
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What is a potential benefit of using an NG tube in the context of an acute GI bleed?
What is a potential benefit of using an NG tube in the context of an acute GI bleed?
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What is indicated by weight loss and change in bowel habits during a patient history review?
What is indicated by weight loss and change in bowel habits during a patient history review?
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If there is ongoing bleeding, which parameter would be monitored using an NG tube?
If there is ongoing bleeding, which parameter would be monitored using an NG tube?
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What is the role of angiography in managing GI bleeding?
What is the role of angiography in managing GI bleeding?
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What is a significant risk factor for gastrointestinal bleeding related to blood disorders?
What is a significant risk factor for gastrointestinal bleeding related to blood disorders?
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Which of the following conditions is associated with impaired synthesis of clotting factors?
Which of the following conditions is associated with impaired synthesis of clotting factors?
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What is a potential side effect of vasocontrictors used in the management of upper gastrointestinal bleeding?
What is a potential side effect of vasocontrictors used in the management of upper gastrointestinal bleeding?
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Which endoscopic technique is NOT generally used for hemostasis?
Which endoscopic technique is NOT generally used for hemostasis?
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How can GI bleed be classified based on its anatomical location?
How can GI bleed be classified based on its anatomical location?
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What complication can arise from the inflation of balloons in a Sengstaken-Blakemore tube?
What complication can arise from the inflation of balloons in a Sengstaken-Blakemore tube?
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What might suggest malignancy during a patient history review?
What might suggest malignancy during a patient history review?
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What might a brisk upper GI bleed falsely present as?
What might a brisk upper GI bleed falsely present as?
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What is the primary lab workup needed immediately for significant GI bleeding?
What is the primary lab workup needed immediately for significant GI bleeding?
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In terms of anatomical classification, where do diverticulosis and carcinoma lie?
In terms of anatomical classification, where do diverticulosis and carcinoma lie?
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Why should normal blood pressure not be used as reassurance in assessing a patient with gastrointestinal bleeding?
Why should normal blood pressure not be used as reassurance in assessing a patient with gastrointestinal bleeding?
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Which sign during a physical examination is more commonly associated with shock due to significant bleeding?
Which sign during a physical examination is more commonly associated with shock due to significant bleeding?
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Which gastrointestinal bleeding presentation may often be life-threatening until proven otherwise?
Which gastrointestinal bleeding presentation may often be life-threatening until proven otherwise?
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Which imaging technique is considered to have limited value in diagnosing acute GI bleeding?
Which imaging technique is considered to have limited value in diagnosing acute GI bleeding?
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What condition is most likely to cause recurrent bleeding in patients?
What condition is most likely to cause recurrent bleeding in patients?
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In which situation is surgery indicated for managing gastrointestinal bleeding?
In which situation is surgery indicated for managing gastrointestinal bleeding?
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What is a common treatment approach before endoscopy in a patient with significant upper gastrointestinal bleeding?
What is a common treatment approach before endoscopy in a patient with significant upper gastrointestinal bleeding?
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What symptom differentiates hematochezia from melena in stool presentation?
What symptom differentiates hematochezia from melena in stool presentation?
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In managing an acute GI bleed, what is typically administered first for volume replacement?
In managing an acute GI bleed, what is typically administered first for volume replacement?
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Which of the following measures is NOT commonly associated with controlling upper GI hemorrhage?
Which of the following measures is NOT commonly associated with controlling upper GI hemorrhage?
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Which of the following interventions is commonly avoided in patients with a history of GI bleeding?
Which of the following interventions is commonly avoided in patients with a history of GI bleeding?
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Which finding during a rectal examination may indicate significant lower GI bleeding?
Which finding during a rectal examination may indicate significant lower GI bleeding?
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Which term describes vomiting blood that has the appearance of coffee grounds?
Which term describes vomiting blood that has the appearance of coffee grounds?
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What is a primary indication for using the Sengstaken-Blakemore tube?
What is a primary indication for using the Sengstaken-Blakemore tube?
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What complication can be effectively managed through angiography during GI bleeding?
What complication can be effectively managed through angiography during GI bleeding?
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What is a potential drawback of using a lower GI contrast study in acute settings?
What is a potential drawback of using a lower GI contrast study in acute settings?
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What is vital to remember about food or medication when assessing symptoms of gastrointestinal bleeding?
What is vital to remember about food or medication when assessing symptoms of gastrointestinal bleeding?
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What condition is suggested by vomiting and subsequent hematemesis?
What condition is suggested by vomiting and subsequent hematemesis?
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Which type of vital sign change would be observed in a patient experiencing significant blood loss?
Which type of vital sign change would be observed in a patient experiencing significant blood loss?
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Study Notes
GI Bleed Definitions
- Hematemesis: Vomiting blood
- Coffee ground emesis: Vomit with dark-brown, coffee-like appearance due to blood
- Hematochezia: Passage of bright red blood from the rectum
- Melena: Dark, tarry stools containing digested blood
- Occult blood testing: Testing for hidden blood in stool
Acute GI Bleed
- Presentation can be subtle or dramatic
- Life-threatening until ruled otherwise
- Mortality rate: 6-14%
- Distinguish upper (above the ligament of Treitz) from lower (below the ligament of Treitz) GI bleed
- Upper: esophagus, stomach, duodenum
- Lower: jejunum, ileum, colon, rectum
Risk Factors
- NSAIDs and aspirin
- Coumadin, Plavix, Pradaxa, Heparin, Thrombolytics
- Steroids
- Alcohol
- Cirrhosis (impaired synthesis of clotting factors, esophageal varices)
- Blood disorders (thrombocytopenia, leukemia, hemophilia)
- Prior GI bleed
Upper GI Bleed Sources
- Ulcer (gastric or duodenal): Most common source (50%)
- Esophageal varices: High likelihood of rebleeding (40-70%)
- Mallory-Weiss tears
- Esophagitis/Gastritis
Lower GI Bleed Sources
- Diverticulosis: Most common cause
- Carcinoma (e.g., colon cancer)
- AVMs
- Infectious diarrhea
- Inflammatory bowel disease (Crohn's, ulcerative colitis)
- Hemorrhoids/anal fissure
History
-
Hematemesis, coffee-ground emesis: Suggests upper GI bleed (90%)
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Melena: Suggests upper GI bleed
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Hematochezia: Suggests lower GI bleed
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Iron and bismuth can mimic melena
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Beets can mimic hematochezia
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Hemoccult test can distinguish
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Duration, quantity of bleed, history of previous bleed
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Weight loss, bowel habit changes: Suggest malignancy
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Vomiting/retching followed by hematemesis: Suggests Mallory-Weiss tear
Physical Exam
- Vital signs: Resting tachycardia, hypotension, tachypnea, check orthostatics
- Skin: Cool, clammy (shock), jaundice (liver disease), petechiae/purpura (coagulopathy)
- ENT: Check for sources of swallowed blood
- Abdomen: Tenderness, mass, ascites, organomegaly
- Rectal: Stool color (bright red, maroon, melena), occult blood
Lab
- Type and crossmatch (if significant bleed)
- CBC (don't assume normal Hgb is reassuring)
- INR/PTT
- LFTs (if appropriate)
- EKG (if elderly or underlying coronary artery disease)
Radiographic Studies
- Abdominal X-rays: Limited value
- Lower GI contrast study: Detects colorectal pathology, may miss mucosal lesions
- Technetium-labeled RBC scan: Localizes bleeding site, very sensitive
- Angiography: Less sensitive, allows embolization
Management
- High-flow oxygen
- Possible intubation (profuse upper GI bleed)
- Cardiac monitor
- Volume replacement (large-bore IV lines, crystalloid)
- Blood transfusion (PRBCs if Hgb < 7, or failure to improve after 2 liters crystalloid, or severe ongoing bleeding. Coagulation factors FFP, platelets)
NG Tube (Nasogastric tube)
- Controversial, can establish source (upper vs lower), monitor for ongoing bleeding, remove blood and clots
Medications
- Proton pump inhibitors (e.g., pantoprazole): Decreases rebleeding rate
- Octreotide, vasopressin: Vasoconstrictors, most effective for esophageal varices
- Side effects: hypertension, myocardial ischemia
Endoscopy
- Upper endoscopy: Diagnoisis and treatment; sclerotherapy, electrocoagulation, laser, variceal banding
- Colonoscopy: For lower GI bleed; requires prep
- Sigmoidoscopy
- Proctoscopy/Anoscopy
Other Measures
- Sengstaken-Blakemore tube: Balloon tamponade for significant upper GI hemorrhage. Possible complications include mucosal ulceration, esophageal/gastric rupture, tracheal compression, aspiration
- Surgery: If medical and endoscopic interventions fail
Some Final Caveats
- Food/medication can mimic bleeding
- Brisk upper GI bleed can present as hematochezia
- Don't be reassured by normal BP, HR, and orthostatic VS. Be more attentive
- Don't be reassured by a normal initial Hgb
- Unstable patients need prompt fluid resuscitation while obtaining a history and physical.
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Description
This quiz covers essential definitions related to acute gastrointestinal bleeding, including terms such as hematemesis, hematochezia, and melena. It also discusses the risk factors and sources of upper GI bleeds, helping you to understand the critical aspects of this medical condition. Test your knowledge on this important topic for healthcare professionals.
