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Block D - Digestion and Metabolism > Pathology -- Gastrointestinal Bleeding > Flashcards

Pathology -- Gastrointestinal Bleeding Flashcards

1
Q

Give 4 types of GI bleeding in decreasing order of incidence

A
  1. UGI bleeding (60.6/100,000)
  2. LGI bleeding (35.7/100,000)
  3. Peptic ulcer bleeding (32.1/100,000)
  4. Colonic diverticular bleeding (23.9/100,000)
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2
Q

Case fatality for UGI and LGI bleeding

A
  • UGI = 2.45%
  • LGI = 1.47%
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3
Q

Case fatality of patients > 75 years with bleeding

A

3.54%

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4
Q

Flowchart to categorize GI bleeding

A
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5
Q

4 upper GI presenting symptoms

A
  • Hematemesis (vomiting of blood or coffe-ground material)
  • Melena (black, tarry stool)
  • +/- hypovolemic shock
  • Hematochezia (passage of red blood or clots per rectum) – 15 - 20% of patients
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6
Q

3 of the most common causes of severe UGI bleeding

A
  1. Gastric or duodenal ulcer (38%)
  2. Gastric or esophageal varices (16%)
  3. Erosive esophagitis (13%)
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7
Q

4 ways to diagnose UGI bleeding

A
  • Medical history
  • Vital signs and physical exam
  • Lab testing
  • Blood urea nitrogen level increases to a greater extent than creatinine level
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8
Q

6 findings in medical history that may point to UGI

A
  • ASA
  • NSAIDs
  • Liver disease
  • Vomiting
  • NG tube
  • GERD
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9
Q

4 lab tests for UGI bleeding

A
  • CBC (hemoglobin, platelets)
  • Chemistry study
  • Liver study
  • Coagulation study
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10
Q

4 parts of the initial management of UGI bleeding

A
  • ABCs (IV, intubation, INR correction)
  • Type and Cross-Match
  • Fluid resuscitation
    • Crystalloid
    • Blood
  • Risk stratification
    • Clinical (Blatchfod, Rockall, AIMS65 scores)
    • Endoscopic
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11
Q

When should patients undergo endoscopic evaluation in the event of UGI bleeding

A

Within 12 - 24 hours

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12
Q

Describe the usefulness of endoscopy with UGI bleeding

A

Identification of the site of bleeding with:

  • 92% sensitivity
  • ~100% specificity

Provides hemostasis if needed

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13
Q

2 drugs to administer just prior to endoscopy of UGIB

A
  • IV prokinetic agent in some (Erythromycin, 250 mg 30 - 60 min prior)
  • Proton pump inhibitor therapy
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14
Q

What is the benefit of administering an IV prokinetic agent pre-endoscopy for UGIB patients?

A

Improve visualization

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15
Q

Benefit of administering pre-endoscopic proton pump inhibitor therapy for UGIB

A

Has not shown to alter clinical outcomes, but may downstage the severity of the lesion and decrease the need for endoscopic intervention

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16
Q

Goal of endoscopic therapy for UGIB

A

Stop acute bleeding and reduce the risk of recurrent bleeding

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17
Q

4 available treatments in endoscopic therapy

A
  • Injection
  • Thermal coagulation
  • Mechanical compression (clips)
  • Hemostatic powders
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18
Q

For which kind of lesions is endoscopic therapy reserved?

A

Lesions that have high-risk stigmata

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19
Q

3 alternative management strategies for refractory UGIB

A
  • Radiological percutaneous procedures (embolization, shunts)
  • Surgery
  • In rare cases, if malignancy, radiation therapy
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20
Q

Medical therpay for non variceal UGIB: why do it?

A

Adjunct to endoscopic hemostasis in patients with high risk endoscopic stigmata

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21
Q

Effect of proton pump inhibitors for non variceal UGIB

A

Profound acid suppression that may promote platelet aggregation and clot formation –> reduce re-bleeding and surgery rates

In patients with high-risk stigmata post endoscopic therapy, high-dose IV PPI x72 hours reduces mortality

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22
Q

How is variceal UGIB treated?

A

Combination of pharmacotherapy, endoscopy, radialogical therapy and (temporarily) balloon tamponade or esophageal stenting

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23
Q

2 pharmacotherapy drugs for variceal UGIB

A
  • Octreotide
  • Somatostatin
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24
Q

2 endoscopy treatments for variceal UGIB

A
  • Band ligation
  • Sclerotherapy
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25
Q

Radiological therapy for variceal UGIB

A

Prosthetic shunting

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26
Q

What does UGIB prognosis depend on?

A

The cause of bleeding

27
Q

Give the prognosis of UGIB based on non-variceal vs. variceal and their rates of rebleeding, surgery and mortality

A
28
Q

Flowchart for overall management of NVUGIB

A
29
Q

How to diagnose lower GI bleeding

A
  • History, physical exam, lab evaluation
  • History of diverticulosis, abdominal cramping followed by bloody diarrhea, reent polypectomy
  • NOTE: Physical exam and lab findings as per UGIB
30
Q

4 key points for LGIB management

A
  • Resuscitation as per UGIB
  • Most patients then need andoscopic evaluation
  • Flexible sigmoidoscopy/anoscopy, especially if anorectal/distal colon bleeding
  • Colonoscopy
31
Q

What is the advantage of colonoscopy for LGIB

A

Allows for diagnosis and possible hemostasis of amenable lesions

32
Q

3 most common colonic sources of severe hematochezia

A
  • Diverticulosis
  • Internal hemerrhoids
  • Ischemic colitis
33
Q

2 therapies for LGIB

A

Urgent colonscopy vs. elective colonoscopy

Endoscopic therapy similar to UGIB

34
Q

If colonoscopy does not reveal the source of bleeding, what should be done?

A

Upper GI endoscopic evaluation

35
Q

If both colonscopy and endoscopic evaluation are negative, what should be done?

A

Capsule endoscopy

36
Q

Alternative therapies if LGI bleeding persists or is too rapid to perform a colonscopy

A
  • Tagged red blood cell nuclear scan
  • Angiography
37
Q

When is a red blood cell scan useful?

A

Only if LGIB is at a rate of at least 0.1 mL/minute

38
Q

When is angiography useful for localization of bleeding?

A

Only when the bleeding rate is of at least 0.5 mL/min

39
Q

3 alternative therapies for LGIB

A
  • Angiographic embolization
  • Infusion of vasoconstrictors
  • Surgery
40
Q

What is the rate of success and risk for angiographic embolization/infusion of vasoconstrictors

A

Success = 80%

Risk of causing local ischemia = 10%

41
Q

Why is surgical management rarely required for hemostasis of LGIB?

A

Most bleeding is either self-limited or easily managed with medical or endoscopic therapy

42
Q

For which patients with LGIB is surgery reserved?

A

Patients with malignant lesions and recurrent or persistent ischemic colitis or diverticular hemorrhage

43
Q

How is the prognosis for LGIB and what does it depend on?

A
  • Depends on cause of bleeding
  • Favorable in most cases
  • Overall mortality rate from LGIB is 2 - 4%
44
Q

Flowchart to determine therapy for LGIB

A
45
Q

Define obscure GIB

A

Bleeding that is persistent or recurrent, despite a negative initial GI evaluation, including:

  • Upper endoscopy
  • Colonoscopy
  • Radiologic evaluation of the small intestine
46
Q

What method will yield a diagnosis in about half of obscure GIB patients?

A

Repeated gastroscopy / colonoscopy

47
Q

Percentage of GIB cases that are considered to be obscure

A

5%

48
Q

Where is the source of bleeding in the majority of patients with obscure GIB?

A

Parts of the small intestine that are beyond the reach of an upper endoscope or colonoscope

49
Q

Most common sources of small intestinal bleeding

A
  1. Vascular lesions (angiectasis)
  2. Ulcers
  3. Tumors
50
Q

Other causes of oscure GIB (not necessarily small intestine)

A
  • Lesions within reach of standard endoscopes not recognized as the bleeding site
  • Intermittently bleeding lesions
51
Q

2 lesions within reach of standard endoscopes which are not recognized as the bleeding site in obscure GIB

A
  • Cameron’s ulcers
  • Internal hemerrhoids
52
Q

Example of an intermitently bleeding lesion which could be defined as obscure GIB

A

Dieulafoy’s lesion

53
Q

What can result in iron deficiency?

A
  • Overt or occult blood loss
  • Iron malabsorption
  • Chronic red blood cell destruction
54
Q

Examples of conditions that cause overt or occult blood loss

A

GI tract lesions

Menorrhagia

55
Q

2 conditions that cause iron malabsorption

A

Celiac disease

Atrophic gastritis

56
Q

Condition that causes chronic red blood cell destruction

A

Hemolysis

57
Q

Flow chart for approach to overt obscure GIB that involves active bleeding

A

NOTE: Go to flow chart for inactive bleeding if all tests negative

58
Q

Flow chart for approach to overt obscure GIB that involves inactive bleeding

A
59
Q

Frequency of lesion types found during double-balloon enteroscopy for obscure GIB

A
60
Q

GI evaluation for iron deficiency anemia is indicated in what 3 groups of people?

A
  • Adult men
  • Pre-menopausal women with a -ve GU w/u
  • All post-menopausal women
61
Q

How to investigate GI if IDA tests are negative

A

Colonoscopy followed by upper endoscopy

62
Q

What method should be performed to look for evidence of celiac disease?

A

Duodenal biopsies

63
Q

If all tests for IDA are negative, what should be performed?

A

Capsule endoscopy with a work up for non-GI causes if negative

Block D - Digestion and Metabolism (29 decks)

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