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management of pt with GI hemorrhage? ABC's, IVF, labs, NG tube to assess whether actively bleeding, stomach irrigated w room temp water/saline until gastric aspirates clear, intubation in pts with massive UGIB/agitation/impaired respiratory status, endoscopy (dx and tx)
Sequence in management of UGIB 1. resuscitation, 2. dx, 3. tx
W/u of suspected UGIB Is bleed acute or occult? Assess physiologic status - severity of blood loss.
Signs of acute UGIB h/o hematemasis, coffee-ground emesis, melena, bleeding per rectum
Signs of occult UGIB s/s anemia, no clear h/o blood loss
how to monitor IV fluid resuscitation 1. UOP, 2. clinical appearance, 3. BP, 4. HR, 5. serial H/H, 6. CVP monitoring
What labs to order in UGIB? CBC, LFT's PT, PTT, type and cross
If UGIB pt has evidence of thrombocytopenia/coagulopathy, what should you do? give plts if thrombocytopenia or FFP if coagulopathy
If UGIB from NSAID use, how to tx? gastric ulcer and gastric erosions from NSAIDs --> empiric therapy w PPI --> endoscopic confirmation
Mallory Weiss Tear coughing/retching/vomiting --> Proximal tear in gastric mucosa --> bleed
How to tx Mallory Weiss tear? bleed is usu self-limited, mild, and amenable to supportive care and endoscopic management
Dieulafoy Erosion. What is the nature of the bleeding and how to tx. bleeding from an aberrant submucosal artery in the stomach. Frequently significant bleeding. Requires prompt ddx by endoscopy and tx by endoscopy or surg.
AVM. What is the nature of the bleeding and how to tx. small mucosal lesion located along GI tract. Bleeding is usu abrupt, rate of bleeding is usu slow and self-limiting.
Esophagitis mucosal erosions frequently resulting from reflux, infxn, or meds
how to pts with esophagitis present? How to tx? occult bleeding; correction of avoidance of the underlying cause
esophageal variceal bleed: what is it? What type of bleeding? Related to what other conditions? engorged veins of GE region that may ulcerate and leave to massive hemorrhage; related to portal htn and cirrhosis
Define shock insufficient physiologic mechanism to adequately supply substrate to tissue
Stage I Shock (ATLS) <750mL blood loss, well compensated
Stage II Shock (ATLS) 750-1500mL blood loss; slight tachycardia, nl BP
Stage III Shock (ATLS) 1500-2000mL blood loss; mod tachycardia, hypoTN
Stage IV Shock (ATLS) <2000mL blood loss; marked tachycardia, prominent hypoTN
define location of UGIB, percentage of all GI bleeds proximal to ligament of Trietz, 80% of all significant GIB
Sources of UGIB 1. variceal (20%), 2. nonvariceal (80%) - includes duodenal ulcers (25%), gastric erosions (20%), gastric ulcers (20%), and Mallory-Weiss tears (15%)
what is the prognosis of UGIB that can't be identified by upper endoscopy? excellent outcome
Rare causes of UGIB neoplasms (B9, malignant), AVM, Dieulafoy
In pts with acute UGIB, what % is self-limiting? 0.8
What is the overall mortality in UGIB? 8-10%
what factors associated with increased mortality in UGIB 1. rebleeding, 2. age, 3. bleeding developed in the hospital
What are the top 5 ddx that causes rebleeding in UGIB, in order of decreasing risk 1. esophageal varices (60%), 2. gastric CA (50%), 3. gastric ulcer (28%), 4. Duodenal ulcer (24%), 5. gastric erosion/gastritis (15%)
Clinical factors associated with increased rebleeding and mortality (6) 1. shock on admission, 2. h/o bleeding requiring transfusion, 3. Hb < 8 on admission, 4. transfusion requirement >5u pRBCs, 5. continued bleeding in NG aspirate, 6. >60 yo (inc mortality, but not increased rebleeding)
Endoscopic factors associated with increased rebleeding and mortality (4) 1. Visible vessel in ulcer base (50% rebleeding risk), 2. oozing of bright blood from ulcer base, 3. adherent clot at ulcer base, 4. location of ulcer worse when near large arteries (posterior duodenal bulb or lesser curvature of stomach)
How do NSAIDs cause UGIB? mucosal damage --> gastric ulcers/erosions
What % of daily NSAID users develop acute ulcers? 0.1
Ways that endoscopy can tx UGIB 1. thermotherapy with heater probe, 2. multipolar/bipolar electrocoag, 3. etOH or epi injections
How to tx nonvariceal UGIB endoscopy with epi injection then thermal therapy; long term with H2blockers or PPI's; test and tx Hpylori; d/c NSAIDs
What to do if NSAID user gets UGIB, but can't d/c NSAID? start prostaglandin analogue such as misoprostol, or replace the non-selective COX inhibitor with a COX-2-selective inhibitor
When in surgery indicated in PUD? PUD with massive persistent or recurrent GIB in association with nonhealing OR ulcers >3cm
What to do if concern for gastric malignancy with bleeding gastric ulcer? gastrectomy or excision of ulcer
How to tx non-CA gastrci ulcers? ligation with vagotomy and pyloroplasty
If UGIB and can't ID source, then what? selective angiography (arterial embolization with gel foam, metal coil springs, clot) - dx and tx bleedingin 70% of pts
Medical tx for PUD arterial vasopressin
Is gastic CA likely to cause acute UGIB? No. More likely to cause anemia 2/2 chronic occult blood loss, wt loss, and anorexia
How do you emergently assess volume status in pt who presents with sx's of acute GIB? clinically. H/H does NOT initially reflect volume status
Tx for variceal bleed endoscopic sclerotherapy + vasopressin/octreotide to dec portal HTN
chance that pt with acute UGIB would bleed again 0.2
Created by: christinapham