Stomach


STOMACH







Low hemoglobin makes oxygen transport to tissue impossible. The heart cannot distinguish between hypoxia, stenosis, carbon monoxide poisoning, and anemia. All are “felt” by the heart as decreased oxygen delivery to tissues.






What is the best next step in the management of this patient?


a. Intravenous (IV) normal saline bolus


b. Wait for hematocrit (Hct)


c. Upper endoscopy


d. Abdominal ultrasonography


e. IV omeprazole


Answer a. Intravenous (IV) normal saline bolus


The most critical part of the initial evaluation of any patient who presents with upper GI bleeding is to assess blood volume replacement and the airway. This patient has no evidence of breathing difficulty but does demonstrate significant circulatory compromise in the form of hemorrhagic shock. The evidence for this is tachycardia, hypotension, and orthostatic hypotension. This patient should immediately have two large-bore IV lines placed and receive normal saline boluses followed by PRBCs. Waiting for the Hct could prove fatal. The first hematocrit is nearly useless if it is normal because it will take hours to see what the real hematocrit is. Volume resuscitation must be done immediately as based on vital signs. This patient has likely lost 35% of his blood volume. You must lose 15% to 20% to become orthostatic. The patient has a pulse higher than 100 beats/min and systolic blood pressure less than 100 mm Hg, which means a 30% volume loss. Starting IV omeprazole is appropriate but is not the best next step in management because hemodynamic stability trumps all other choices. The patient is not stable enough for upper endoscopy, and ultrasonography has no role in upper GI bleeding.


What is the demarcation point between upper and lower GI bleeding?


a. Esophagus


b. Stomach


c. First and second parts of duodenum


d. Ligament of Treitz


Answer d. Ligament of Treitz


Upper GI bleeding is defined as any bleeding that occurs proximal to ligament of Treitz, which delineates the crossover point between the duodenum and jejunum.







Systolic blood pressure <100 mm Hg and heart rate >100 beats/min = ≥30% blood volume loss.


“Orthostatic” means a systolic blood pressure drop of 20 mm Hg and diastolic drop of 10 mm Hg or heart rate increase of 10 beats/min.











It’s all in the stool!


• Red blood demonstrates lower GI bleeding or very high-volume upper GI bleeding


• Coffee-ground emesis: 5 to 10 mL of blood loss proximal to the ligament of Treitz


• Black stool: upper GI bleeding from 100 mL of blood loss


• Heme-positive stool: brown from 5 to 10 mL of blood loss











CCS TIP: Any patients who presents in shock with hypotension not responsive to fluids must be admitted to the ICU.


Move the clock forward 15 to 30 minutes. The patient receives a 2-L bolus of normal saline.


Results:


CBC: Hct: 28


Gastroenterology consults tells you nothing of use.


PT: 1.2


PTT = 28 seconds (normal)


Blood urea nitrogen (BUN)/creatinine = 45/1.2


ECG: Sinus rhythm with nonspecific ST changes


Order:


Obtain vital signs.


Move the clock forward 2 minutes to get the results.


Results:


Heart rate, 84 beats/min; lying flat, 94 beats/min standing


Blood pressure, 118/76 mm Hg; lying flat, 108/72 mm Hg standing


CCS TIP: All consults on CCS say, “I saw your patient. There are no specific recommendations.” Never expect a CCS consultation to help you answer the case.










High BUN with GI bleeding = Renal hypoperfusion + Blood in gut = High BUN






Which is a mechanism of high BUN-to-creatinine ratio in prerenal azotemia from decreased renal perfusion?


a. Increased filtration of protein at the glomerulus


b. Decrease in antidiuretic hormone (ADH) effect at the proximal tubule


c. Afferent arteriolar dilation


d. ADH increases urea reabsorption at the collecting duct


Answer d. ADH increases urea reabsorption at the collecting duct


ADH places aquaporins into the collecting duct at the kidney. This increases water reabsorption from the collecting duct and into the renal medullary interstitium. This would dilute the concentrating ability of the kidney. ADH also puts “urea transporters” directly into the collecting duct and causes direct urea reabsorption in the collecting duct.







Hct <30 + Old = PRBCs


Hct <25 + Young = PRBCs


International normalized ratio (INR) >1.5 = fresh-frozen plasma (FFP) and vitamin K


Platelets <50,000 with active bleeding = transfuse






What is best next step in the management of this patient?


a. Endoscopy


b. Angiography


c. Bleeding scan


d. IV omeprazole


e. IV ranitidine


Answer d. IV omeprazole


IV proton pump inhibitor (PPI) therapy is the best next step in management and should be initiated in all patients with suspected upper GI bleeding before endoscopy as part of the initial set of orders. PPI therapy has been shown to reduce rebleeding, downgrade the severity of the lesions, and promote healing of the stomach lining caused by increased pH. PPI therapy also promotes clot stabilization and therefore improves outcomes. Endoscopy should be done concurrently, but PPIs are tried first. Angiography is only for failed endoscopic hemostatic control with endoscopy, and the bleeding is massive. Bleeding scans are only for lower GI bleeds when you think there is blood loss likely happening but you do not know for sure. Nuclear bleeding scans are quite nonspecific. Ranitidine does not adequately raise stomach PH above 4 and is not nearly as useful in upper GI bleeding as a PPI.







H2 blockers (eg, ranitidine)


• Do not raise stomach PH adequately


Tachyphylaxis


• IV H2 therapy does not reduce morality rates but only promotes healing of the ulcers.











Three stimulants of acid/H+ from gastric parietal cells:


• Histamine


• Acetylcholine/vagal stimulation


• Gastrin






What is the best next step in the management of this patient?


a. Endoscopy


b. Angiography


c. Surgery


d. Nasogastric tube


Answer a. Endoscopy


After adequate volume resuscitation, correcting for anemia, and coagulopathy, the best next step is upper endoscopy known as esophagogastroduodenoscopy (EGD). EGD allows for diagnosis and intervention of the bleeding site. Endoscopy is the best initial diagnostic and therapeutic procedure. A nasogastric tube is wrong because it does not change management. If you are going to do an upper endoscopy, placing a nasogastric tube does not matter. There is nothing you can do therapeutically through a nasogastric tube. Lavage or decompression is not meaningful.







Order an endoscopy and then turn the clock forward. You will get the report from the procedure.











PPI + Endoscopy: All patients


Nuclear (technetium) bleeding scan: suspected GI bleed; source not found with scope


Angiography: localizes source of bleeding to guide surgery











Sources of upper GI bleeds


• Peptic ulcer: secondary to Helicobacter pylori or nonsteroidal antiinflammatory drug abuse


• Variceal bleeding: cirrhosis


• Mallory Weiss tear: preceded by forceful vomitus


• Arteriovenous malformation: seen commonly in aortic stenosis











Move the clock forward enough for the patient to undergo an EGD.


A large ulcer (Figure 8-1) is noted in the antrum with a nonbleeding visible vessel. Epinephrine and a sclerosing agent are injected into the vessel for hemostasis. Biopsies are taken to assess for H. pylori.






images


Figure 8-1. Gastric antral ulcer. (Reproduced, with permission, from Wong Kee Song L, Topazian M. Gastrointestinal endoscopy. In: Longo DL, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.)







H. pylori


• Microaerophilic helix shaped


• Gram-negative bacterium


• Produces oxidase, catalase, and urease










Smoking and alcohol only impair ulcer healing. They do not cause ulcers.











Forrest classification of endoscopic findings. As you progress down the list, the rate of rebleeding decreases.


• Class Ia: Spurting hemorrhage


• Class Ib: Oozing hemorrhage


• Class IIa: Nonbleeding visible vessel


• Class IIb: Adherent clot


• Class IIc: Flat pigmented spot


• Class III: Clean ulcer base











After endoscopy, order a CBC the next morning and turn the clock forward.


CCS TIP: The Hct should be higher or stabilized from admission. If it is lower, then the case will continue.











Move the clock forward 12 to 24 hours. The repeat CBC shows that the Hct is still 24 after the patient received 2 more units of PRBCs.










GI bleeding stops spontaneously in 80% of patients.






What is the best next step in the management of this patient?


a. Endoscopy


b. Angiography


c. Surgery


Answer b. Angiography


After a failed endoscopy, the best next step to control bleeding is angiography with coil embolization of the vessel. Success rates for patients with acute peptic ulcer bleeding can reach 98%, with recurrent bleeding rates up to 20%. Patients should have a serum creatinine less than 1.5 mg/dL and an INR less than 1.5 and a platelet count greater than 50,000.







Nasogastric tube


• No therapeutic role


• Will not stop the bleeding











After angiography, order:


BUN/creatinine


CBC


Move the clock forward. If the case does not end, prepare for a curve ball.


Twenty-four hours later when you are on rounds, the Hct is still 22 despite 6 units of PRBCs. The patient is still tachycardic.






What is the best next step in the management of this patient?


a. Endoscopy


b. Angiography


c. Surgery


d. Add an H2 blocker to the PPI


e. Add sucralfate to the PPI


Answer c. Surgery


Surgery is the best next step in the management of complicated peptic ulcer disease (PUD) with persistent or massive recurrent GI bleeding. Additionally, if a patient presents with hemodynamic instability despite vigorous resuscitation, or shock with recurrent hemorrhage, surgery is indicated. Surgical treatments for PUD include oversewing of the artery with truncal vagotomy, or antrectomy with gastrojejunostomy (Billroth II procedure).


Dec 22, 2016 | Posted by in GYNECOLOGY | Comments Off on Stomach
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