What are the modes of clinical
presentation with GI bleeding ?
Answer
- Hematemesis
- Hypotension
- Anemia
- Black tarry stools
- Hematochezia
What are the anatomical sites from which GI
bleeding can occur?
Answer
- Bleeding can occur anywhere from oropharynx
to rectum.
What are the mode of presentation of acute
GI bleeding?
Answer
Acute bleed:
- Hematemesis
- Hypotension
- Melena
- Hematochezia
What are the mode of presentation of chronic
GI bleeding?
Answer
Chronic bleed:
What
are the causes for black stools?
Answer
Black
stools
-
Bloody
(Upper GI bleeding): Tarry and sticky with foul smell Melena
-
Non-bloody (no
smell and not sticky)
-
Therapeutic
intake of iron
-
Pepto-Bismol
(bismuth compounds)
-
Licorice
What
are the clinical manifestations of Hypovolemia?
Answer
-
Lightheadedness
-
Postural
hypotension.
-
A drop greater than 10 mm of Hg in erect position.
What are the findings supporting acute GI bleeding?
Answer
-
Manifestation
of hypovolemia.
- Anxiety,
lightheadedness, restlessness.
- Pale,
moist skin.
- Orthostasis,
tachycardia
- Weak
peripheral pulses
-
Absorption
of blood
-
Loss
of blood
-
Decreased
hemoglobin with normal
MCV.
-
Altered
blood
What is the likely
location of bleeding site in the GI tract when there is melena?
Answer
Above
the ligament of treitz. Hydrochloric acid converts hemoglobin to:
- Duodenal
ulcer
- Gastric
ulcer
-
Gastritis (gastro-duodenal erosions)
-
Esophagitis
(GERD)
-
Esophageal
varices
-
Mallory-Weiss
tear
-
Arteriovenous
malformations
-
Swallowed
blood from hemoptysis or oropharyngeal bleed
Estimate
the amount
of blood loss required to produce each of the following:
-
Occult
blood
-
Melena
-
Orthostasis
Answer
When
will you consider duodenal
ulcer as the etiology for GI bleeding?
Answer
- E
epigastric burning with similar episodes in past
- Epigastric
tenderness on exam
- The
history of alcohol, smoking, NSAID’s use and aspirin use
(predisposing factors)
When
will you consider esophageal varices as the etiology for GI bleeding?
Answer
Esophageal
varices
- In a cirrhotic with portal hypertension
- Physical
findings of cirrhosis (spider nevi full parotid glands)
Gastro-duodenal
erosions. Abuse of NSAID
Esophagitis
(GERD). History of reflux.
Mallory-Weiss
tear. Retching followed by hematamesis.
Arteriovenous
malformations. In a patient with stigmata for hereditary hemorrhagic
telengiectasia.
Swallowed
blood from hemoptysis or oropharyngeal bleed
What
historical
information should one gather in evaluation of acute upper GI bleed?
Answer
-
Stool
characteristics
-
Intake
of
-
iron
-
Pepto-Bismol
(bismuth compounds)
-
licorice
-
Symptoms
of hypovolemia
-
Use
of NSAID's: Can give rise to gastritis or precipitate bleeding from ulcers
-
Epigastric
distress
-
GERD
symptoms
-
Retching
-
Nose
bleeds
-
History
of alcoholism, cirrhosis and portal hypertension
-
History
of aortic surgery
What
are the physical
findings you should be looking for in GI bleeding patients?
Answer
-
Manifestation
of hypovolemia
-
anxiety,
lightheadedness, restlessness
-
pale,
moist skin.
-
orthostasis,
tachycardia
-
weak
peripheral pulses
-
Finding
encountered in Cirrhosis suggesting possible esophageal varices as a source
of bleeding
-
spider
nevi.
-
full
Parotid glands
-
hepatomegaly
-
splenomegaly
-
hyperestrogenism
-
Finding
indicating hereditary hemorrhagic telengiectasia
-
Careful
exam of oropharynx for bleeding sites if any
What
are the prioritized
steps that should be taken in the ER to treat patients suspected of having upper
GI bleeding?
Answer
- Brief
history/physical exam
- Assessing
the degree of circulatory compromise by doing orthostatics
- Establish
IV access with 2 large bore IV’s
- Volume replacement
- Type
and cross-match for blood
- Laboratory
evaluation to include CBC, coags, BUN, creatinine
- Nasal oxygen
- EKG
- Nasogastric tube
- Consult
with endoscopist and surgical colleagues
- Detailed
history to assess for underlying diseases which increases morbidity and
mortality
What are the interpretations for the possible returns
from nasogastric tube?
- Coffee grounds
- Red blood/clots
- Bile stained
- Clear
Answer
- Coffee grounds: slow bleeding
or oozing
- Red blood/clots: active
ongoing bleed
- Bile stained: no active
bleeding above the Treitz ligament. A
bile stained NG aspirate would make active bleeding proximal
to the third portion of the duodenum most unlikely
- Clear: GI bleeding is often
times intermittent and can stop spontaneously. The
clear return suggests a competent pylorus and bleeding could be still
occurring in the bulb and going postbulbar
What
is the ideal procedure to confirm the location of bleeding site and why?
Answer
Once
the patient has stabilized (no orthostasis, slowed pulse) an upper GI
endoscopy (EGD) would be the procedure of choice
- EGD
is diagnostic and can be therapeutic if active bleeding or
visible vessels are seen
- Injection
therapy with epinephrine or a variety of electro coagulation techniques
(heater probe, laser coagulation) can be used to stop bleeding
- EGD
in this cases would rule out varices (a cause of severe UGI hemorrhages)
- Also
the EGD could permit a biopsy to evaluate for Helicobacter pylori, a
causative agent in most peptic diseases.
A biopsy would be taken from an area of the antrum, not from or in
close vicinity to bleeding lesions.
70
plus%
of UGI bleeds will cease spontaneously. Should EGD be done even after the bleeding
stops?
Answer
EGD should be done in
every case
- The
EGD can provide useful information (diagnosis) as well as being therapeutic
in needed instances
- Tissue
can be obtained
- The
endoscopic findings can help assess the risk for recurrent hemorrhage
(rebleeding increases mortality)
What
are the factors
that increase the mortality and morbidity from UGI bleeding?
Answer
- Rebleeding
after initial presentation
- Severity
of bleeding ( > 5-6 units)
- Diagnosis (varices)
- Age > 60
- Multisystem
disease (co-morbidity)
- Endoscopic
stigmata of recent bleeding (visible vessels)
- Onset
of bleeding in hospitalized patient
- Need
for emergency surgery for bleeding
Which patients
are likely to rebleed?
Answer
Patients
who present with:
- Hypotension
- Multiple
medical illnesses
- Hematemesis
- Hematocrit under 30
- Inability
to clear the stomach with aggressive gastric lavage
- Ulcer
showing:
- red
spots/Ulcer base 10%
- clot
20%
- visible
vessel 50%
What
is the indication
for surgical intervention in upper GI bleeding?
Answer
- Most
patients can be managed with nonresectional therapy
- Surgical
intervention should be considered with:
- large
bleeding lesions in the stomach
- lesser
curvature lesions
- bleeding
ulcers associated with gastritis
- Patients
who bleed after endoscopic therapy should be considered for operation
after resuscitation with 6 units of blood. This is an arbitrary cutoff
but is a useful marker for severity of bleeding.
- Surgery
may require subtotal or near-total gastrectomy for control of hemorrhage
What
is the alternative
option for surgery?
Answer
- Arteriography
with embolization should be reserved for the unusual patient who has either a
difficult location of the upper gastrointestinal bleeding or co morbidities that
prohibit operation
What
are the types
of anemia that result from GI bleeding?
Answer
- Microcytic
hypochromic anemia in chronic blood loss
- Normochromic
normocytic anemia in acute blood loss
What
are the types
of lesions that can cause chronic bleeding in GI tract?
Answer
What
are the required
evaluations/tests for iron deficiency anemia in a male adult ?
Answer
- Stool
for occult blood
- Full colonoscopy
- flexible sigmoidoscopy would be inadequate, as it would evaluate
to the level of the splenic flexure, at best
- If
the colon was negative, then the remainder of the GI tract would have to be
examined (EGD and small bowel series with barium)
What
is hematochezia?
Answer
Bloody bowel movement
This
generally
indicates a lower GI tract hemorrhage from the colon or distal ileum
What
is melena?
Answer
Melena
is black, sticky, tarry, malodorous stool
- Usually
from an upper GI bleed, above the colon
- 100-200
cc of blood to produce melena
- Digestive
enzymes act upon the blood to change the color and consistency
What
is occult blood?
Answer
Occult
blood is blood not detectable with the naked eye. It requires a special test to
confirm its presence.