GI bleeding
Black tarry stool. White gauze, rub finger on it
Gauge black stool
Guaiac positive stool, not positive
Low hemoglobin, don’t have a source, have a low acuity source. In and out of the hospital
Fecal occult test
Hematological
Melena lose about 50 ccs of blood
50ccs in the literature
Tar, distinect cell
Ulcers, Varices, GAVE,
Mucosal bleers, tears, arteriovenous dileufoy lesion
Diverticular
Aortoenteric fistula
surgery
BUN creatinine ratio > 30
325 patients
Nasogastric tube in patient with varices, variceal tear.
Massive hematemesis. Consulting GI.
Diffuse esophageal hemorrhage, did lavage, that is negative.
Negative aspirate
Diffuse alveolar hemorrhage
Kidney biopsy, retroperitoneal hemorrhage
Aspirate if patient does not have varices.
Bright red blood upper gi bleed, gastric lavage.
Donate bag of blood 500ccs.
750 -1500 a lot
MTP 2000
Too stable to scope, too sick to scope
Window of scoping
If you don’t resuscitate will lead to mortality
Anesthesia
Anesthetics, drops blood pressure, extra hypoperfusion, strains the heart increases mortality
Hematocrit remains the same with loss of whole blood
Correct coagulopathy
1 ffp for every 4 uprbc
Vitamin K, anticoagulation
Judicious cirrhotics, elevated portal pressures, when you give increased volume, increases in portal pressure and open up.
Judicious blood transfusions to organ transplant, an organ, have adverse effects.
RH factor, type and screen, fluid overload, and bleeding
Transfusion <7
Adequately perfusing
Blood, ffp if coagulopathy
Reverse anticoagulation if on warfarin / Xarelto, treat bleeding, cause stroke / DVT / PE
Judicious
Bleeding shouldn’t be reflex
Bleeding minimally don’t have to stop reversing things, hold medications
Liberal verse restrictive transfusion
Taking into account, heart, lungs, start overtransfusing
11- 12 above 7
At 7-8 patients did well
Complications
Bleeding didn’t kill the patient
Secondary cause that led to mortality
Kidneys get impacted, heart. Over time that will be poorly
Patients rarely bleed to death? GI bleed, resuscitate, scope within
Use all factors to determine when to scope
Inpatient scope
Based off of labs, mental status, lower threshold.
Subjective
Pre-endoscopic pharmacotherapy
Acute episode of bleeding
Increases motility to clear out blood from stomach
30 to 90 units
IV ppi 80mg bolus
For ulcer
Rationale, increase pH, pH over 6 stabilizes clots.
Role of PPI in patients with upper gi bleed. Long term study. Lesser need for endoscopic therapy
Scope without ppi,
Scope someone on ppi, off ppi forest classification. Characeterizing ulcer high, medium, low risk
PPI convert forest 1A to Forest 3, convert ulcer. In 48 hours if you weren’t on PPI more likely intervention
Friday still oozing.
Still scope them
Only use H2 if there is a shortage of PPI
Endoscopy, most of the time ulcers are healed
Scoped patients on PPI, rarely have to treat
1a, 2b or c
Already have a clot, up to you if you want to clot
Cause bleeding, cratered into submucosa.
48 hours doesn’t treat it, keep pH high enough that the ulcer doesn’t worsen and allow it to heal
Sucralfate bismuth, salicylate, coats the ulcer, use esophagitis. Increase the pH, overall the barrier that covers the ulcer. Only lasts 4 hours, do it every 4 hours, suspension, still secrete gastric fluid and suspension that can wash it away. Not in algorithm of UGIB, can add it
Sucralfate to get relief.
PPI w/ H2 blockers, same efficacy. Even in intubated patients post GI stress ulcer prophylaxis. PPIs superior.
Inject 1:10,000
1:100 if cardiac
Inject and clip
Adherent clot:
Clean base ulcer – do nothing class III
Biopsies, blood vessels / specimen
h. pyloris
Rebleeding in 48-72 hours if not treated
Epinephrine, thermal electrocoagulation
Mechanical hemoclips
Duo therapy better than monotherapy
Thermal electrtocoagulation probe
APC: argon
Hair spray with lighter, argon plasma
Thermal plugging
Endoscopic therapy PPI drip 72 hours then PO
High dose over non high dose, h. pylori status
Malignancy
Heaped up ulcer
Not just ulcer, biopsy can be malignant
Cratered ulcer, malignant ulcer, biopsy corners
Not comfortable biopsying, send back for repeat endoscopy
Discharge on ppi, nsaids and aspirin, continue nsaids, if can’t, should be on PPI. Aspirins, CAD, PPI indefinitely.
Alcohol binge for weeks to months varices, discriminant function
Bleeding give them steroids
Don’t always have cirrhosis, transient liver dysfunction which causes them to back flow from portal system
Hepatic venous pressure gradient
Needle in portal vein, measure portal pressures
<5-6 nml
At around 10-11 varices
>12 bleed
IR stent, connect hepatic vein and portal vein
Decreases varices
Leads to hyperammonia
Become
Pltlt < 88 k
Palpable speen, platelet count / spleen diameter
BUN, bilirubin child pugh
Important prognostic factor for variceal bleed is the size of varices,
Rubber band around barrett’s, if band misfires can cause bleeds
Beta blocker
Primary / secondary ppx, band and give beta blockers
Band every 4 weeks?
Come back for repeat banding
Variceal bleed
Vasoconstrictors therapy, anbitiocis, resuscitation, ICU level of care, endoscopy, alternative erescue, beta blockade
Octreotide
Antibiotics, translocation of bacteria can get SBP.
Go to ceftriaxone
Prophylactically treat varices
Varice size is important, large column of varices, primary prophylaxis of bleeding, band them?
Primary prophylaxis.
Band them, you are committed to banding
Banding them every 4 weeks keep banding
Beta blockers and see how they are
Beta blockers, stop bleed see varices
Secondary prophylaxis already have it. Band and
Primary / secondary prophylaxis
Resuscitation ICU level of care
Endoscopy – Blakemore / TIPS
Blakemores
Vasoconstrictor
Varices, any reason,
Barrett’s variceal screening
Don’t want to bleed in the future
When you see varices, don’t have to band them, some ppl don’t like banding
Give them prophylaxis, decrease the size or get rid of varices
When you band them, continue to band them until they eradicate
Band them once, not on beta blocker nonselective beta blocker
Banding, Dr. Patel
If you don’t band them and don’t bring them back, start from square one
Can band the same vessel
Esophageal varices, distal to proximal
Ban above GE junction rest of
Band in spiral fashion don’t get all
Distal to proximal pull best bands first. See in 4 weeks if you did a good job
Lower proximal to distal
Continue to band until it becomes gone
Proximal esophagus will patient feel it? ,ge junction feel it
Vasopressin
Octreotide somatostatin analogue
No proven
50mcg bolus then 50mcg/hr drip for 3-5 days
Convert to nonselective nadolol, pindolol
Get out of ICU.
Can put on for 7 days
4 types
One that is banded
IGV1 greater curvature
Fire band IGV1
GOV don’t band
Therapy not by banding, blue or coils.
Splenic vein thrombosis, collateral veins
Feed distal to proximal
Banding at source of where they are engorged
Splenic vein thrombosis, will get gastric varices. Veins around stomach,
Tie a bag of saline at the end of the tube, hold if over a pull. Water fill balloon against an esophagus.
Manual tamponade
Not more than 12 hours
Can cause necrosis of esopahgus
12 horus
Come back loosen it then pump it back up
Barbaric
Aspiration, migration, necrosis perforation of
Bleeding no banders, drop fully covered metal stent.
Release it, opens up and pushes pressure against esophagus, manual tamponade.
Place stent, then get banded and tips can migrate
Varices, take it out can rip through
Expandable tent, not mesh can’t expand. Covered stent no holes, transparent
Malignancies of the GI tract keep it open in growth to keep stent in place.
Bridging therapy
Nadolol higher compliance
Propranolol twice a day
Holding parameters
HR 30 not next dose, heart rate and blood pressure
Propranolol poor compliance
Nadolol once a day, longer half life, spread throughout the day, less fluctuation
Carvedilol superior
Alpha 1 hepatic vasodilation decreases portal pressure
12.5 mg BID
Right colon, terminal ileum, by the time blood gets to the end
Melena doesn’t have to be from the upper, upper is the more dangerous, scope them
One case, melanotic patient, hds patient, long record in hospital. CAD.
Upper endoscopy. Melena
Deferred colon as outpatient.
Melanotic bleed have large cancer
Blood gets oxidized and turns black.
Elective
Hematochezia upper gi bleed.
Radiation proctitis, post-polypectomy
Dieulafoy’s submucosa lesion without ulcer, bleed like crazy, cardia fo the stomach,
Lose lots of blood, normal mucosa, pinpoint.
Handful of dieulafoy’s lesions hard to find
Diverticulosis large volume, painless.
Drip blood, clip and bare claw
Lots of bleed
IR not prepped, clots and blood, want GI to do colonoscopy first
Diverticuloar bleed, never tripped. All blood hard to see.
CTA bleeding scan, IR go in and embolize
GI go in with endoscopy
Don’t want to embolize if not needed, can cause ischemia
Actively bleeding hard to find active bleeding
IR don’t want to actively embolize if don’t have to
Lack of standardized approach
Colonoscopy after resolution of bleeding large volume bleed can prep
First prep
Burst prep gallon of golytely over 4 hours
Not good
Golytely administered 1 every 30-45 minutes
1 hour after prep, colonoscopy
Enema then colonoscopy
No benefit in mortality / outcome
Purge prep
CTA versus Tagged RBC, bleed that is oozing 0.05 – 0.1ml/min
0.5 to 1 ml/min for CTA
Tagged RBC has to be actively bleeding, stopped bleeding w/in 1 hr still works
There is a rate
5 coloonoscopyies two uppers, do a tagged RBC scan
Stabilize for surgery
Hemicolectomy?
Removed segment out that is affected
Pending positive cta
Rectal examination
Some ppl larger fingers
Severe hematochezia
Don’t just
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