Podcast
Questions and Answers
What is the most common cause of upper GI bleeding?
What is the most common cause of upper GI bleeding?
Upper GI bleeding occurs below the level of the ligament of Treitz.
Upper GI bleeding occurs below the level of the ligament of Treitz.
False
What are the symptoms of significant blood loss in gastrointestinal bleeding?
What are the symptoms of significant blood loss in gastrointestinal bleeding?
Vomiting red or black blood, bloody stool, black stool, abdominal pain, shortness of breath, pale skin, passing out.
What is one of the primary goals of evaluating a patient with a bleed?
What is one of the primary goals of evaluating a patient with a bleed?
Signup and view all the answers
The ligament of Treitz connects the right crus of the diaphragm to the ________.
The ligament of Treitz connects the right crus of the diaphragm to the ________.
Signup and view all the answers
A history of renal disease does not affect management decisions in bleeding patients.
A history of renal disease does not affect management decisions in bleeding patients.
Signup and view all the answers
Match the following causes of upper GI bleeding to their percentages:
Match the following causes of upper GI bleeding to their percentages:
Signup and view all the answers
What is a common complication of small amounts of gastrointestinal bleeding over time?
What is a common complication of small amounts of gastrointestinal bleeding over time?
Signup and view all the answers
Name a medication that predisposes individuals to peptic ulcer formation.
Name a medication that predisposes individuals to peptic ulcer formation.
Signup and view all the answers
NSAIDs are a less common cause of ulcer bleeding in females.
NSAIDs are a less common cause of ulcer bleeding in females.
Signup and view all the answers
Signs of mild to moderate hypovolemia include _____ tachycardia.
Signs of mild to moderate hypovolemia include _____ tachycardia.
Signup and view all the answers
List one sign of chronic gastrointestinal bleeding.
List one sign of chronic gastrointestinal bleeding.
Signup and view all the answers
Which condition is associated with Helicobacter pylori infection?
Which condition is associated with Helicobacter pylori infection?
Signup and view all the answers
Patients with a high score (>8) during evaluation are considered low-risk.
Patients with a high score (>8) during evaluation are considered low-risk.
Signup and view all the answers
Mallory-Weiss syndrome accounts for ________% of upper GI bleeding.
Mallory-Weiss syndrome accounts for ________% of upper GI bleeding.
Signup and view all the answers
Which of the following is not a feature of acute upper GI bleeding?
Which of the following is not a feature of acute upper GI bleeding?
Signup and view all the answers
What type of examination should be carried out to identify bleeding lesions in the upper gastrointestinal tract?
What type of examination should be carried out to identify bleeding lesions in the upper gastrointestinal tract?
Signup and view all the answers
Coagulopathies and thrombocytopenia indicate difficulty in controlling _____ during patient management.
Coagulopathies and thrombocytopenia indicate difficulty in controlling _____ during patient management.
Signup and view all the answers
Match the following conditions with their potential impact on bleeding assessment:
Match the following conditions with their potential impact on bleeding assessment:
Signup and view all the answers
What is a concern during physical examination in cases of acute abdomen?
What is a concern during physical examination in cases of acute abdomen?
Signup and view all the answers
What is the recommended time frame for performing upper endoscopy for most patients with upper GI bleeding?
What is the recommended time frame for performing upper endoscopy for most patients with upper GI bleeding?
Signup and view all the answers
Therapeutic endoscopy can achieve acute hemostasis and prevent recurrent bleeding in all patients.
Therapeutic endoscopy can achieve acute hemostasis and prevent recurrent bleeding in all patients.
Signup and view all the answers
What is the critical imaging finding of gastrointestinal bleeding on CT angiography?
What is the critical imaging finding of gastrointestinal bleeding on CT angiography?
Signup and view all the answers
Patients with suspected variceal bleeding should undergo endoscopy within ______ hours of presentation.
Patients with suspected variceal bleeding should undergo endoscopy within ______ hours of presentation.
Signup and view all the answers
Match the contraindications of upper endoscopy with their descriptions:
Match the contraindications of upper endoscopy with their descriptions:
Signup and view all the answers
Which of the following is NOT a risk associated with upper endoscopy?
Which of the following is NOT a risk associated with upper endoscopy?
Signup and view all the answers
Fluid resuscitation for hemodynamically unstable patients should be delayed pending transfer to an intensive care unit.
Fluid resuscitation for hemodynamically unstable patients should be delayed pending transfer to an intensive care unit.
Signup and view all the answers
What needs to be measured to assess a patient's preoperative status before endoscopy?
What needs to be measured to assess a patient's preoperative status before endoscopy?
Signup and view all the answers
Therapeutic interventions during endoscopy may lead to increased ______.
Therapeutic interventions during endoscopy may lead to increased ______.
Signup and view all the answers
What should be established for emergency access in patients with upper GI bleeding?
What should be established for emergency access in patients with upper GI bleeding?
Signup and view all the answers
Study Notes
Management of Upper Gastrointestinal Bleeding
- Gastrointestinal bleeding (GI bleed) encompasses all bleeding within the gastrointestinal tract, from the mouth to the rectum. Significant blood loss over a short period may present as vomiting red blood, black blood, bloody stools, or black stools.
- Mild GI bleeding over a longer time may lead to iron-deficiency anemia, resulting in fatigue, chest pain, pale skin, shortness of breath, or even fainting. Some cases may present without symptoms.
Classification of GI Bleeding
- Upper GI bleed: Bleeding above the Treitz ligament.
- Lower GI bleed: Bleeding below the Treitz ligament.
Ligament of Treitz
- A fibromuscular band extending from the right crus of the diaphragm to the duodenojejunal flexure.
- The upper portion is composed of striped muscle fibers, the lower portion of smooth muscle fibers, and the middle portion is made of elastic fibers.
Upper GI Bleed Causes
- Peptic ulcer: 60%, often triggered by NSAIDs, steroids, or alcohol. Duodenal ulcers bleed more frequently than gastric ulcers.
- Gastroduodenal erosions.
- Esophageal varices.
- Oesophagitis and erosions.
- Stomach cancer (5%).
- Mallory-Weiss syndrome (5-15%): tears in the lining of the esophagus or stomach, sometimes triggered by excessive vomiting.
- Vascular anomalies(Dieulafoy's syndrome, Osler-Weber-Rendu, Ehlers-Danlos), Aortoduodenal fistula.
- Bleeding disorders.
- Medication use (anticoagulants, clopidogrel, aspirin).
Clinical Features of GI Bleeding
Acute Bleeding
- Signs of shock
- Hematemesis (vomiting blood)
- Melaena (black, tarry stools)
Chronic Bleeding
- Hypochromic microcytic anemia
- Glossitis (inflammation of the tongue)
- Koilonychia (spoon-shaped nails)
- Congestive heart failure
- Mortality rate in upper GI bleed: 10%.
Initial Evaluation
- Detailed medical history.
- Physical examination.
- Laboratory tests.
- Assess bleed severity.
- Determine potential sources of bleed.
- Identify conditions that may impact treatment.
Past Medical History
- Liver disease/alcohol use.
- Abdominal aortic aneurysm/aortic graft.
- Renal disease/aortic stenosis/hereditary hemorrhagic telangiectasia.
- Peptic ulcers (especially if associated with H. pylori infection, NSAID use, antithrombotic use or smoking).
- Malignancy (in patients with a history of smoking, excessive alcohol consumption, or H. pylori infection).
- History of volume overload (renal disease, heart failure, etc)
- Risk of difficult-to-control bleeding, like coagulopathies or hepatic dysfunction (more intervention needed)
Medication History
- Medications associated with peptic ulcer formation (aspirin and NSAIDs).
- Medications associated with increased risk of bleeding (anticoagulants, antiplatelet agents, certain antidepressants, antihypertensives).
Physical Examination
- Hypovolemia (15% or less blood volume lost).
- Resting tachycardia.
- Signs of acute abdomen and organ damage.
- Signs of significant comorbid illnesses
Investigative Procedures
- Endoscopy (gastroscopy) to locate & treat bleeding source within 24 hours.
- CT angiography (CTA) for active bleeding in the celiac trunk and SMA, look for contrast extravasation and arterial phase images.
- Blood counts and other laboratory tests (Hb, packed cell volume, prothrombin time, platelet counts, blood urea, serum creatinine, electrolytes, CVP & U/S abdomen).
Contraindications for Endoscopy
- Difficulty swallowing.
- Noncompliance with care.
- Cardiac devices (pacemakers or defibrillators-relative).
- Major abdominal surgeries within 6 months (relative).
- Pregnancy.
- Risks of endoscopy - aspiration, adverse drug reactions, GI perforation, increased bleeding during intervention. This needs evaluation in high-risk patients, such as recent myocardial infarction.
Treatment of Upper GI Bleed
General Measures:
- IV access (2 gauge or larger/central line)
- Fluid resuscitation (initiation immediately and avoiding delay in critical cases)
- Catheterisation
- Nasogastric tube (Ryle’s tube) aspiration
- Blood transfusions (if Hgb < 7 g/dL)
Medications:
- Acid suppression (PPI intravenously) for acute bleeding.
- Vasoactive medications (somatostatin, octreotide, terlipressin) for variceal bleeding
- Prokinetics (erythromycin or metoclopramide) to improve visualization during endoscopy.
Endoscopic and Surgical Modalities
- Endoscopy - for bleeding source identification & treatment (cauterization, laser, injection therapy, etc)
- Embolization of the gastroduodenal artery for high surgical risk.
- Surgical intervention (in cases of persistent bleed) - various procedures like ligation of the bleeding vessel, partial gastrectomy, or potentially vagotomy/antrectomy. Indications include failure of endoscopic therapy, signs of uncontrolled bleeding, high blood loss
- Surgical procedures for Varices, different techniques like transection and anastomosis, and other procedures.
Bleeding Stomach Ulcer
- Endoscopy (cautery, laser, injection therapies-first consideration).
- Embolization - for ongoing bleed & endoscopic failure.
- Laparoscopy (ulcer bed underrunning/stitching).
- Partial gastrectomy with Billroth I anastomosis (a reconstruction or reconnection to reduce risk of recurrent bleeding).
- Vagotomy with antrectomy to reduce recurrence
Bleeding Esophageal Varices
- Primary prophylaxis - treatment preventing first episode
- Drugs to reduce portal pressure (propranolol, isosorbide mononitrate)
- Endotherapy (methods for stopping bleed)
- Secondary prophylaxis - treatment after initial bleed
- Endotherapy.
- Shunt surgeries
- Drugs (propranolol)
Emergency Management in Severe Bleeding
- Volume and electrolyte correction.
- Blood product administration
- Intubation & ventilation
- Critical / intensive care management
- Antibiotics, nutrition, and vitamin K.
- Catheterization and monitoring hourly urine output.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
This quiz focuses on the key concepts related to the management of upper gastrointestinal bleeding. It covers the classification, causes, and symptoms associated with GI bleeding. Understanding these aspects is crucial for recognizing and treating patients effectively.
