Lange Current Emergency Medicine - GI Bleed Chapter

Chapter 16: GI Bleeding CS edits Study online at quizlet.com/_2hdnt7 1.

AAA / aortoenteric fistula suspected - if stable confirm with

bedside US, CAT Scan

15.

Factors that increase morbidity and mortality in these patients

2.

_____________________accounts for 50% of upper GI bleeding;

Peptic ulcer disease; consider initiating protonpump inhibitor therapy

Hemodynamic instability, ongoing symptoms, inability to clear bleeding with lavage, age of 60

16.

GI bleeds - more prominent M/F?

males, elderly (both upper and lower bleeds)

3.

Angiodysplasia Characterized by

painless bleeding that may be mild or massive occult blood in stools to melena to hematochezia.

17.

Hemobilia - caused by

- trauma, hepatic tumors, gallstones and parasites - bleeding from the ampulla of Vater; (upper GI bleed)

4.

Angiodysplasia most common in

patients older than 60 w/ history of cardiac or renal disease

18.

history/risk factors; ongoing hemorrhage

5.

Any elderly patient whose complaints of abdominal pain are out of proportion to examsuspect as what?

Mesenteric ischemia

Aortic fistula/history AAA repair Esophageal varices GI bleeds Diverticulosis

19.

history to take

Barium enema used to study lower GI bleed?

no; interfere with endoscope & visceral angiography

alcohol, NSAIDS, anticoags, weight loss, stool caliber, AAA repair, liver disease, abdominal surgery

20.

in the presence of: Portal HTN and coagulopathies

bright red clots in aspirate of NG tube - indication for?

gentle gastric lavage

how can gastritis cause bleeding (doesn't usually on its own) ?

21.

every 4 hrs

C/C of Colitis (whole section doesnt diff UC vs Crohn's?)

abdominal cramps, diarrheal stools containing blood and mucopurulent material, fever, weight loss, anemia.

how frequent to check hematocrit with active GI bleed, after hemostabilization?

22.

How to Dx hematochezia

Proctoscopy to visualize hemorrhoids

23.

How to Dx Meckel's Diverticulum?

Technetium scan or angiography

24.

If given permission, what may you also do if persistent GI bleeding is present? in prep for endoscope

-Place NG tube with increments of 200-300 mL of either saline or tap water -Patient should be in LLD position with the bed in reverse Trendelenburg -Lavage until the return is clear -Adm of erythromycin IV will stimulate gastric motility and will also help to clear the stomach of blood prior to endoscopy

25.

if hematochezia from UPPER GI source...

massive hemorrhage; mortality

26.

if melena associated with LOWER GI source...

intestinal tract motility decreased (over 14 hrs); also pseudo-melena; pepto or iron

27.

instructions for peptic ulcer - avoid

smoking alcohol NSAIDS, aspirin caffeine

28.

Is contrast media typically used in patients with GI bleed?

No. May obscure endoscopic viscualization

6.

7.

8.

9.

C/C of patients with diverticulosis

Cramping, lower abdominal pain, LLQ tenderness. May also have: - tenesmus, constipation, diarrhea

10.

Chief complaint of people with anal fissures?

Painful bowel movements. Will also see bright red blood post-wiping

11.

Chief complaints of GI bleed

Hematemesis hematochezia-bright red; lower GI (sigmoid, rectum) melena-tarry; upper GI (stomach/duod)

12.

Colonic polyps

Painless rectal bleeding and discovery of a polyp on sigmoidoscopy, colonoscopy, or barium enema confirm the diagnosis

13.

14.

Crohn's disease findings

differentiating colitis; ischemic colitis rarely affects

Frank blood, abdominal pain, anorexia, diarrhea, weight loss, fatigue, fistula formation, fissures, hemorrhoids are common rectum

29.

is initial hematocrit always low?

no; often normal - until fluids introduced shows dilution

30.

Lower GI bleed most commonly the result of what?

Diverticular disease; then angiodysplasia, colonic ulcers

Mallory-Weiss Syndrome

Tears in the esophageal mucosa and submucosa that usually occur after forceful retching and vomiting; (alcohol* use usually factor)

32.

Mallory-Weiss Syndrome also reported following

chest compressions, coughing, sneezing, BM straining

33.

meckel's diverticulum

True diverticulum at umbilicus due to persistence of vitelline duct. May contain gastric acid-secreting tissue leading to perforation.

34.

Meckel's Diverticulum mc in

children under 2 yrs; rarely after 10 yrs

35.

meckel's diverticulum pic

31.

36.

Meckel's Diverticulum S&S

may mimic appendicitis -Hemorrhage is most common complication, also intestinal obstruction

MOA of somatostatin / octreotide

reduces splanchnic blood flow & GI motility, inhibits acid / secretions (vasoconstrictor - inhibits GH, insulin, glucagon)

38.

Most common cause of esophageal varices in the US

alcohol and viral cirrhosis; (parasitic liver infestations -> cirrhosis elsewhere)

39.

Most common cause of hematochezia in adults?

Hemorrhoids

Most likely causes of lower GI bleed in adolescent or young adults?

meckel's diverticulum IBD, polyps

Most likely causes of lower GI bleed in adults over 60?

angiodysplasia diverticula neoplasms

37.

40.

41.

42.

Most likely causes of lower GI bleed in adults under 60?

diverticula IBD neoplasms

43.

percentage of pts which upper or lower gi bleeds stop?

most; 80-85% prior to ED arrival -although can be intermittent, can restart at any time

44.

Pharm treatment for peptic ulcer ?

Omeprazole or rabeprazole; somatostatin; octreotide

45.

The presence of telangiectasias of the skin and lips may indicate which disease?

Osler-Weber-Rendu disease (hereditary hemorrhagic telangiectasia) - AD disorder!

46.

Rule out infectious colitis; such as

shigella, campylobacter, entamoeba histolytica, c. diff, and salmonella

47.

Should GI bleed patients receive anything by mouth?

No

48.

Solitary Rectal Ulcer Associated with

rectal prolapse May result from straining at stool. Patient passes blood and mucus per rectum -elderly and have chronic constipation

49.

S/S of ongoing hemorrhage

Hematemesis or hematochezia Hypotension, tachy, shock (or Postural hypotension, lightheadedness)

50.

Tenderness to palpation in the epigastrium is common with what 2 diseases?

Gastritis Peptic ulcer disease

51.

Treating colitis

Surgery if severe. Medical measures if mild-moderate

52.

Treating colonic polyps

Removal of polyps if bleeding persists

53.

Treating Crohn's disease

Bowel rest, NG suction, IV fluids. Surgery is rarely indicated.

54.

Treating esophageal varices

NG tube, Octreotide Sclerotherapy, band ligation, Sengstaken-Blakemore tube tamponades hemorrhage

55.

Treating hemobilia

Embolization via interventional radiographic technique

56.

Treating hemorrhoids

High fiber diet, stool softeners, surgery if severe

57.

Treating Mallory-Weiss Syndrome

Lavage until clear, PPI or sucralfate to reduce acid/bile

58.

treating Meckel's Diverticulum

Hospitalize, surgery if severe bleeding, intestinal obstruction, diverticulitis, and umbilicoileal fistulas

59.

Treating nonbleeding suspected gastritis

GI cocktail"; Antacid with lidocaine, also: PPI, H2 antagonists

76.

What will suggest the presence of Mallory-Weiss tears?

Vigorous retching or vomiting prior to onset of hematemesis

60.

Treating Rectal Ulcer

aid defecation. Avoid surgery

77.

What will you hear on auscultation in upper GI bleed?

61.

Treatment of angiodysplasia

Electrocoagulation, embolization through angiography

Hyperactive bowel sounds (the blood stimulates peristalsis)

78.

When should patients get intubated?

Massive hematemesis or S/S of shock

79.

When should rule out duodenal source of bleeding? ????

If gastric lavage contents reveal bile

80.

When should transfusion be considered?

Persistent hypotension despite infusion of 2 L of crystalloid

81.

When should you obtain orthostatic blood measurements?

If initial SBP is >100 and pulse