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What are some general characteristics of active upper GI bleeding?
- -VERY SERIOUS
- -7-10% mortality
- -Hematemesis, melena, or BRBPR
- -Melena: 50-100ml blood loss in upper GI tract
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When upper GI bleeding is present, what are some of the causes and frequencies of occurrence?
- -Peptic ulcer disease (PUD) -> (>50%)
- -Portal HTN: Esophageal bleeding most common (10-20%)
- -Mallory Weiss tears (5-10%)
- -Vascular ectasias (7%)
- -Gastric neoplasms (1%)
- -Erosive gastritis/esophagitis (<5%)
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What do you need to do during a UGI bleeding assessment?
- - DETERMINE HEMODYNAMIC STATUS!
- - Orthostatic blood pressure and pulse
- - Resuscitation if unstable
- -NG tube: red or coffee ground aspirate confirmes upper GI bleed
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How do you administer an upper endoscopy (EGD)?
- -Identify source of bleed
- -Determine risk of rebleeding
- -Render endoscopic therapy ->Cautery ->Clips ->Injection
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What pharmacologic treatment is administered to patients for UGI bleed?
- -Proton Pump Inhibitors
- -Octreotide
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Give some general information concerning Acute Lower GI Bleeds.
- -Defined as bleeding arising below the ligament of Treitz (95% of cases arise from the colon)
- -Less likely to have orthostasis than upper GI bleeds, or require transfusions
- -Mortality is less than 3%
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What are the causes of Acute Lower GI Bleeds?
- -Diverticulosis -Vascular ectasias
- -Neoplasms -Inflammatory bowel disease
- -Anorectal disease -Ischemic colitis
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What is Diverticulosis?
- -Most common cause of MAJOR GI bleeding (50%)
- -Most diverticula are on left colon
- -Most diverticular bleeding from right colon
- -Presentation is acute, painless, large volume BRBPR
- -Bleeding subsides spontaneously in 80%
- -May rebleed in 25%
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What is Vascular Ectasias?
- -Occurs throughout entire GI tract
- -Painless
- -5-10% of lower GI bleeds
- -"Spider veins of the GI tract"
- -Most common in >70 yo and in chronic renal failure
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What are Neoplasms? (lower GI bleeding)
- -Benign polyps and carcinoma
- -Usually chronic, occult blood loss
- -10% of lower GI bleeds
- -Apple core lesions
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What are some characteristics of Inflammatory Bowel (acute lower GI bleed)?
- -Variable amounts of hematochezia
- -Abdominal pain, tenesmus, and urgency are often present
- -Crohn's disease
- -Ulcerative colitis
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What is an anorectal disease? (acute lower GI bleed)
- -Small amount of blood on toilet paper, or streaking stool
- -Internal hemorrhoids cause painless bleeding
- -Pain with BM suggests anal fissure
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What is Ischemic Colitis (acute lower GI bleed)?
- -Most common in older patients, especially those with atherosclerotic disease
- -In young patients, look for vasculitis, coag disorders, estrogen, long-distance runners
- -Bleeding is usually mild and self-limited
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Name some other causes for acute lower GI bleeds.
- -Radiation-induced proctitis
- -Infectious colitis
- -Solitary rectal ulcer
- -Colonic varices
- -Small bowel diverticula
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Acute Lower GI Bleed: Evaluation -> Color of stool
What does blood-streaked stool suggest?
-Distal lesion
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Acute Lower GI Bleed: Evaluation -> Color of stool
What does a large volume of BRBPR suggest?
-Colonic source
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Acute Lower GI Bleed: Evaluation -> Color of stool
What does Maroon suggest?
-right colon or small intestine
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Acute Lower GI Bleed: Evaluation -> Color of stool
What does black (melena) suggest?
-Above ligament of Treitz
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Acute Lower GI Bleed: Evaluation -> Color of stool
What does 10% BRBPR suggest?
-upper GI source (massive bleed)
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How would you exclude an upper GI bleed source?
-NG tube
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With an acute lower GI bleed, if the patient is not anemic and less than 45 years old, then what would you perform?
-Anoscopy and Sigmoidoscopy
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What would you perform to evaluate an acute lower GI bleed in a patient >45 or with anemia?
-Colonoscopy
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What can be performed to localize an acute lower GI bleed?
-Nuclear bleeding scans
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After unexplained, recurrent bleeds, how would you evaluate the small intestine as a source?
-Enteroscopy/capsule imaging
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How are acute lower GI bleeds managed?
- -Discontinue ASA and NSAIDs
- -Therapeutic colonoscopy (can deliver epinephrine, cautery, or endoclips)
- -Intra-arterial vasopressin or embolization
- -Surgery for ongoing bleeding
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Less than _____ of blood loss may not cause any change in stool appearance.
100 mL/d
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How is occult bleeding identified?
-FOBT or FE deficiency anemia
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What are the causes of occult GI bleeding?
- Neoplasms
- Vascular abnormalities
- Acid-peptic lesions (esophagitis, PUD)
- Infections (nematodes, TB)
- Medications (NSAIDs, ASA)
- Inflammatory bowel disease
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If a patient is >40, has alarm symptoms, FH of GI cancer, or anemia disproportionate to menstrual loss, what tests should be performed?
Colonoscopy or EGD
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What is the pathological accumulation of fluid in the peritoneal cavity?
Ascites
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What conditions cause ascites associated with normal peritoneum?
- Portal hypertension (>80% of patients)
- Hypoalbuminemia
- Salt & water retention by kidneys
- Pancreatic, biliary, chylous, nephrogenic
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What conditions cause ascites associated with diseased peritoneum?
- Infections (TB)
- Malignancy
- Inflammatory disorders
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What are the risk factors for liver disease?
- ETOH
- Transfusions
- Needle use
- History of viral hepatitis
- History of cancer
- Fever (bacterial peritonitis)
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What are the signs of ascites?
- Jugular venous distension (JVD) (R-sided CHF) (Constrictive pericarditis)
- Hepatomegaly: If tender, acute alcoholic hepatitis or Budd Chiari
- Large abdominal wall veins (Cephalad flow indicates portal htn) (Inferior flow indicates hepatic vein obstruction)
- Caput medusae
- Chronic liver disease
- Supraclavicular or periumbilical lymph nodes (malignancy)
- Shifting dullness (1500mL)
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What are the signs of chronic liver disease?
- Palmar erythema
- Cutaneous spider angiomas
- Gynecomastia
- Dupuytren's contracture
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What establishes the presence of fluid with ascites?
Abdominal ultrasound
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What establishes the cause of fluid in ascites?
Abdominal paracentesis (Cell count, albumin and TP, culture and gram stain)
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What is the best single test to distinguish between portal hypertensive and non-portal hypertensive causes of ascites?
Albumin and total protein (SAAG)
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If the serum-ascites albumin gradient is greater than 1.1 g/dL (high), what are the possible causes of ascites?
- Cirrhosis
- Chronic hepatic congestion
- Nephrotic syndrome
- Massive liver metastases
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If the serum-ascites albumin gradient is less than 1.1 g/dL (low), what are the possible causes of ascites?
- Peritoneal carcinomatosis
- Peritoneal TB
- Nephrotic syndrome
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What condition shows: no apparent intra-abdominal source of infection, most patients have chronic liver disease
Spontaneous bacterial peritonitis
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Why do patients with chronic liver disease get spontaneous bacterial peritonitis?
- The ascites fluid is static
- Fluid that doesn't move gets infected
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What are the signs and symptoms of spontaneous bacterial peritonitis?
- Fever
- Abdominal pain
- Mental status changes
- Worsening of renal function
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What is the most important diagnostic test for spontaneous bacterial peritonitis?
Abdominal paracentesis
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