1. - GI bleeding is a/w 10% MORTALITY, THUS 1st: stabilize by ABC; 2nd: NASOGASTRIC TUBE to determain if the source of the bleeding is from the upper or the lower G.I. - Melena(black digested stool) is from upper G.I. Bleeding of 50ml; - Hematochezia ( fresh blood with stool ) is from sever upper OR lower GI bleeding. - Ligament of Treitz is at the duodeno-jejuna junction. - Bleeding proxmal to this ligament is upper GI bleeding, and bleeding distal to this ligament is lower GI bleeding. - Orthostatic hypotension (aka postural hypotension)BP falls greater than 20/10 mm H when the person stands up. - GI bleeding with INR more then 1.5, or increased PT Rx: fresh frozen plasma. -MCC of lower GI bleeding is: Pt.< 50 years: infectious colitis, hemorrhoids, fissures, and IBD;;if Pt. > 50 years: diverticulosis, vascular ectasias, ischemia, CA octeotride decreases portal hypertention only used for variceal bleeding GI varices Rx is never sclerotherapy is NEVER USED ANYMORE, banding is the new and best method norfloxacin is a varices rx for prophylaxis for varecial bleed to prevent the asociated with spontanious bacterial peritonitis propanolol is used to prevent the next bleed and given to patient after stablizing, and they contiunue using it at home TIPS is if you do everyting and the pt is still bleeding the degree of platlets decrease from normal limit is not associated with the the function of the platletes as log as the platelest are more then 50, 000mm3 any hypoperfution of the kedny ( hypovolemia ) causes prerenal azotemia high BUN/Cr more then 15 blood in the gi will lead to increase BUN urne Na is low if patient shiting blood= think upper or lower, then the NG is a must, to Dx upper of lower alcohol does not cause ulcers, but it causes erosive gastritis which can NEVER cause stomach CA alchohol and tabaco delay healing they do not cause ulcer gastric ulcers can cause stomach CA NSAID can cause a gastric ulcer, and erosive gastritis everytime a patietn is Dx with a new ulcer = repeat endoscopy to rul out CA Malory wise synd= a NON-trans-luminal tear= no perforation = no added rx needed it is self-limiting bleeding anything that makes you cough too much can cause hemoptysis, andything that makes you vomit too ( mallory wise)much can cause hematemsis coffe ground emesis= vomiting with about a tea spoon of bl blood loss of about 20% causes orthostasis blood loss of about 30% causes sys BP less then 100 and or a pulse of more then 100 ANY GI bleeding get scoped, the questions is should we look through the esophagus, the colon, or both
2. Floating Topic
3. Floating Topic
4. GI bleeding
   1. 1st: vitals
      1. I. Tachycardia
      2. II. orthostatic Hpotetion
      3. III.Shock=systolic BP less then 100
         1. must give I.V. Normal Saline, continuous; give PRBC if more then 2L. NS is given
   2. 2nd: Rx: ABC
      1. Stat 2 I.V. 18G w/
      2. Clear airway, keep NPO
         1. nasogastric suction
      3. continuous cardiovascular monitor of:
         1. BP
         2. cardiac
         3. pulse oximetry
   3. 3ed: Physical Exam after stablizing the pt.
      1. GI with Digital rectal exam & anoscopy
      2. HEN, CNS,CVS, & Lungs
   4. 4th: order tests
      1. CBC w/ Differential, and cross matching
      2. BMP
         1. BUN & Creatinine
         2. K, Na, Ca,Cl,HCO3,Glucose
      3. LFT
      4. bleeding profile
         1. PT, aPTT, INR
      5. Nasogastric Tube Lavage
         1. +blood= UPPER GI Bleeding= Do ENDOSCOPY
         2. - blood= Do Colonoscopy
5. Lower GI bleeding
   1. Diverticulosis(artery bleeding)
      1. Mild-Rx. High fiber diet
      2. Severe-Rx. Surgery
   2. Angiodisplasia
      1. a/w AORTIC STENOSIS
   3. Hemorrhoids(venous bleeding)
      1. lower GI Bleeding=Internal: Superior to DENTATE-line. INSENSITIVE
         1. 1st degree: − Prolapse.
         2. 2ry degree: + Spontaneously reducing prolapse.
         3. Third degree: + Prolapse requiring manual reduction.
         4. Fourth degree: + Non-reducible prolapse.
         5. Rx.I. increase water & fiber in diet, stool softeners, & Sitz bath; II.Band ligation; III. hemorrhoidectomy
      2. Painful tender bluish mass & NO BLEEDING=External: Inferior to the DENTATE-line very sensitive
         1. Rx. I.increase Fiber & water- is usually self limiting ; II. if thrombosed- office excision
   4. Mucosal edema & ulceration seen at areas of least collateral blood (watershed areas) recto-sigmoid & splenic flexure w/ Risks of Coronary heart disease
      1. Dx. ischemic colitis
6. Sever bleeding = Do Angiogrophy
7. limited bleeding = Do technetium-labeled RBC scan
8. PEPTIC ULCER DISEASE, most common cause of UGB; Hx.
9. Esophageal varices (20% of all cases of UGB; Hx. liver disease)
   1. Rx. I. Octeotride (IV) & Endoscopic Banding (Sclerotherapy not as effective as Banding), add propanolol after stabilization. II. TIPS ( Sengstaken-Blakemore tube might be used while prepping for surgery), III. Surgery
10. MALLORY-WEISS TEARS, 10% of all UGB, Hx: repeated vomiting, or alcoholism
11. VASCULAR ANOMALIES, 5% of UGB, Hx: CRF, CREST synd., telangiectasia
12. GASTRIC CANCER-rare
13. EROSIVE GASTRITIS -rare
14. Main Topic 7
    1. Subtopic 1
       1. Subtopic 1
          1. Subtopic 1
             1. Subtopic 1
             2. Subtopic 1
             3. Hemolytic reactions may be acute (within 24 h) or delayed (from 1 to 14 days).
             4. Subtopic 1
             5. Subtopic 1