Approaching the GI Bleed - CRASH! Medical Review Series

[@woloabel]

Thursday, November 3, 2022. Gastroenterology: Approaching The Gastrointestinal Hemorrhage/Bleeding is the Hemorrhage of the Gastrointestinal Tract (Oral Mucosa to Annus Localization) known as Bleeding/Diathesis where the Ligament of Treitz separates the Upper/Lower Anatomy by Convention. The General Principles of Bleeding: Ax of Upper GI Bleeding (Most Common to Least): 1) Peptic Ulcer Disease (PUD) with 1) Gnawing Pain and usually due to Excessive NSAID use; Tx is PPIs (Omeprazole, Pantoprazole et al) via Mouth (PO); 2) Gastritis (Dx is via Endoscopy for Differentiation of PUD) shows Gnawing Pain (Epigastric Pain) usually due to NSAID use, Alcohol Consumption or Tobacco use; Tx is PO Proton Pump Inhibitors (PPIs) and IV if Symptomatic Complications (Vomiting); 3) Mallory Weiss Tear (MWT) presents with 1) Retching (Reverse Movement or Dry Heaving) and 2) Sudden Acute Bleeding (Association with Bing Alcohol Consumption; 4) Gastroesophageal Varices has GI Bleeding due to Alcoholism (Chronic Use) Complication or Liver Disease. Portal Hypertension has the Dilatation of the Venus Vessels of the Mesenteric System/Mesenterium as the Pathophysiology (Venus Congestion); Dx is via Endoscopy (Upper Endoscopy) in Patients with Refractory Hematemesis; Tx is 1) Variceal Band Ligation (Treatment of Choice [TOC]). 2) If this is Unsuccessful (Refractory Hematemesis), a Transjugular Intrahepatic Portosystemic Shunt (TIPS) Procedure is Possible and Next best Option. 3) Daily Propranolol, A Non Cardioselective Beta-Blocker. In Lower GI Bleeding: Ax: 1) Diverticulitis is the Complication/Inflammation of Outpouching Diverticula with Left Lower Quadrant (LLQ) Pain, A History of Constipation, and in Elder (Geriatric) Subjects. 2) Hemorrhoids are Venous Internal/External Swellings (Dilatation); SSx: 1) Anorectal Pain If External; and 2) Possible (Association/Aetiology) due to Chronic Constipation (History); 3) Infectious Diarrhea is due to a Self-Limiting Inflammation of the Intestinal Mucosa due to Infectious Aetiology (Association/Risk Factors are 1) Sick Contact Exposure [Pathogen Exposure], 2) Food Exposure (Foodborne Pathogens), and 3) Travel to Endemic Areas (Vibrio cholerae); SSx: 1) Fever, 2)Diarrhea (Possibly Bloody); 4) Inflammatory Bowel Disease (IBS) is Autoimmune Chronic Inflammation of the Intestinal Mucosa. SSx: 1) Fever and 2) Multiple Extraintestinal Symptoms (Anemia, Pyoderma Gangrenosum), and 3) Chronic Diarrhea; 4) Arthritis, 5) Weight Loss, and 6) Primary Sclerosing Cholangitis in Ulcerative Colitis; 7) Multiple other Systemic SSx. Tx is merely Symptomatic. Cure of this Disease is unavailable currently; 5) Ischemic Colitis is Inflammation of the GI Mucosa due to Ischemia (Obstruction and Necrosis) or Lack of Perfusion; SSx: 1) Severe Pain (10/10); Hx of Atrial Fibrillation and/or Risk Factors for Embolism; 6) Colon Cancer is Neoplasia/Anaplasia Localized to the Colon (Adenocarcinoma Malignancy); SSx: 1) Change in Stool Caliber, 2) Anemia of Chronic Disease (Fatigue, Pallor, Dyspnea, Tachycardia et al); 7) Angiodysplasia is a Small Vascular Malformation in the GI Tract (Non-Genetic Aetiologic Cause). Angioectasis or Arteriovenous Malformation (AVM) are a Common Cause of GI Bleeding. Tx is via Endoscopic/Anoscopic Band Ligation is First Line Therapy (However, the Most Common endoscopic Therapy is Aragon Plasma Coagulation Ablation); 2) Radiologic Therapy (Mesenteric Angiography) with Cauterization (Burning); or 4) Surgery of Segmental Resection of the Intestine can be Curative; 8) Intussusception (Bowel Obstruction) is the folding of the Small Intestine usually so as to cause Ischemia, Infarction or other Complications. Bowel Obstruction with this Aetiology is a Medical Emergency. Dx is via Abdominal Ultrasound; Tx is via a Barium Enema (Advanced Imaging and Air Contrast Enema and/or Surgery Dissection/Resection of the Segment via Open/Laproscopic 1) Rectoplexy or 2) Stapled Transanal Rectal Resection (STARR Procedure); and Further Treatment of Lower GI Hemorrhage: 1) Post Fluid Resuscitation/Stabilization via IV NS Bolus; 2) Endoscopy (Visualization of the Relevant Structure for Diagnostic and Aetiologic Purposes) is Effective in 85% of Cases. An Alternate to Endoscopy (Colonoscopy) is 1) Tagged RBC (Nuclear RBC Scan), a Nuclear Medicine Procedure, is a Radioisotopic Method of Visualization (Used when Endoscopy is unsuccessful) via a Gamma Camera Scan; and 2) Capsule Endoscopy can also assist in the Investigation of Source of GI Hemorrhage (Aetiology). Pediatric Lower GI Bleeding Causes (more Rare Incidence): 1) Meckel's Diverticulum; 2) Intussusception; 3) Necrotizing Enterocolitis (NEC); and 4) Juvenile Polyposis Syndrome (JPS); 5) Gastric or Esophageal Malignancy/Cancer has Refractory GERD with Risk Factors/Associations of Alcohol and Tobacco Use; and 6) Esophagitis marked by Odynophagia or Painful Swallowing; also, 7) Aortoenteric Fistula is a rare but Possible Aetiology of GI Bleeding (Status Post Abdominal Aortic Aneurysm Repair Surgery). Signs and Symptoms: 1) Hematemesis (Upper), 2) Melena (Upper > Lower), 3) Maroon Stools (Lower > Upper), or 4) Bright Red Blood Per Rectum (BRBPR) is usually indicative of Lower GI Bleeding. Dx: 1) Clinical. 2) Anemia Investigations (CBC/CMP); 3) Coagulation Studies (Basic screening tests include 1) CBC, 2) PT/PTT, 3) Bleeding Time or Platelet Function Assay (PFA-100), 4) Thrombin Time (TT), and 5) Peripheral Blood Smear (PBS). Tx (Severe Bleeding) is IV NS Bolus. In Patients/Subjects with History of 1) Liver Disease, 2) Alcoholism, 3) Hematemesis, IV Octreotide is Indicated. Therefore, a History (Hx) is a good Diagnostic Tool. Emergency Treatment of GI Bleeding (Severe Bleeding/Acute Hemorrhage): 1) Fluid Resuscitation via Immediate NS Bolus (Hematemesis, Bloody Diarrhea, Hypotension/Orthostasis [Dizziness/Vertigo/Lightheadedness). 2) IV Octreotide (Hematemesis, Liver Disease History [Cirrhosis]) is Somatostatin Analog Drug Class, Alcoholism Dx); Laboratories Relevant and/or Diagnostic Measures: 1) Electrocardiogram (ECG/EKG); 2) Complete Blood Counts (CBC); 3) PT/PTT (Characterization of Coagulation); 4) Type and Crossmatch (Blood Transfusion/Transplantation Purposes); The later Diagnostic Measures will guide Treatment and Management where: 1) Anemia (Hemoglobin < 8) will warrant Packed Red Blood Cells (PRBCs); 2) Thrombocytopenia (Platelets < 50) will Warrant Platelet Transfusion; 3) Elevations of PT or PTT (aPTT) warrant Fresh Frozen Plasma (FFP). Goodness, this idea of the GI being Necrotic or Neoplastic is a Magnificent Conundrum. Thankfully, my first ever Investigation of Bleeding Diathesis was merely a Cirrhotic Complication leading to Hepatorenal Syndrome Type II, an equally challenging Mystery. MD Paul Bolin, man gegen die Natur eine verlorene Ursache ist, aber man gegen man unerlässlich nicht muss sein. Trotzdem, es ist. Heil!

[@medstudyplaylist9295]

I love your way of teaching - thank you so much Dr. Bolin

[@lovableluckyandfriends]

Thank you for being my professor, Dr. Bolin.

[@ayajamal5639]

Thank u so much for fixing the problem can update liver video too ?!

[@nicholasmatuza728]

A sincere thanks to Dr. Bolin!

[@venkataccount]

Awesome fabulous lecture..very crisp and clear. Thanks a lot dr.paul..

[@eugeniosramos]

Please keep up with the videos, those are great. Thank you!

[@Jtrp73]

YOU'RE AMAZING, DR. BOLIN X

[@rhuundamckenzie2237]

Thanks for sharing your knowledge with us Dr. Bolin. Jesus bless you.

[@elhamalduaij9352]

This is SO helpful, thank you very much! شكرا جزيلا

[@shavegassutton9607]

00

[@ummesalamaabizer62]

Thanks for updating the video!

[@TheTechNerd-s7g]

Are you sure about endoscopy for lower GI? I looked into some guides, and they say you do upper GI endoscopy if unstable otherwise DRE and Sigmoidscopy for low colon cancer risk and colonoscopy for high risk patients.

[@nnm7883]

thank you ..شكرا

[@sajedaaltamimi5785]

Amazing explanation ✨

[@amineharrat7450]

Good lecteur DOCTOR Paulin

[@mr.medtech731]

Thanks for these videos.

[@nuamah4229]

Please I want to verify something. Is it not Diverticulosis rather that bleed because diverticulitis is an inflammatory process where most of the vessels are thrombose

[@vincentngassa300]

Hi Peggy! Actually, diverticulitis develops on a background of diverticulosis. Diverticulosis is the formation/presence of unnatural pouches (diverticula) along the GIT while diverticulitis is the inflammation of the diverticula. So bleeding can occur in either or both of them, as mentioned in 26:07 of the video. Hope this helps!!!

[@DrDinooshDeLivera]

These video are great!!! Thank you so much.

[@vanirampersad794]

Thanks !

[@sajadesign6354]

Very helpful thank you so much 🌸🌷

[@introvertedbookkeeper9447]

Thank you for uploading this!

[@MyLifeGNWhyte]

Ur the best thanks for re doing it

[@sondanh8657]

Thank you.^;^

[@shereenshabin9056]

Thank you!

[@darkestnbl]

radioisotope boi