DIP Episode 377 - The Clutch GI Bleed Podcast

Okay, welcome. This is episode 377. After the Vine intervention podcast and into these podcasts we're going to be talking about GI bleeding. GI bleeds, the things that pop up on step two, CK extensively, pop up on step three extensively. And you also show up on many shelf exams. Pretty much every shelf exam shows up maybe with the exception of like peeds, actually, peeds is just peeds is a little more specialized. But for the most part, GI bleeds are those things you know you're going to see on your exam. You know that if you don't learn it, you know you're going to get questions wrong. So let's talk about it. But today this podcast is going to be focused more on management. I mean something that is very important. I suspect that in the future I'm going to make podcasts where I address GI bleeds. We'll start talking about pathophysiology and talking about specific diagnoses you can make based on certain things that we give you in the question. And again, if you're taking a USML step two, CK step three exams or complex level two or three exams, any time within the next four weeks I'm offering an MBA me test against strategy scores. It's going to be taking place on the 21st of March from 2 to 4 30 p.m. Pacific standard time. And then from the 22nd to the 25th of March, I'm going to be having a 24 hour course which is going to be running from 7 a.m. Pacific standard time to 1 p.m. Pacific standard time on each of those four days. That's basically 10 a.m. to 4 p.m. Eastern.

Again, if you're interested, just shoot me an email through the website and I'll give you some more information again. I've had tons of people attend these courses. They've done really well on the exams again. Pretty much every Wednesday that they release scores. I get emails from people that, wow, they're fine. Thank you. I pass my exam. My score went up 30 points, 40 points, 50 points. Again, I've had some pretty significant score increases. Even with the test against strategy scores, I've seen people, many people were even be a Cuban percentage, it's went up significantly after taking the course. So again, these courses, they're very well put together, they're very helpful for people studying for the exam. Then if you're taking your US Emily step 2 CK or step 3 or complex level 2 or 3 exams in the summer, I have a 75 hour school that's going to be taking place in the first two weeks of May. That one, because I really want to invest super deeply in everyone that's attending. I'm going to copy that 40 people. I can't have more than 40 so that I can really pay attention to the needs of everyone. So, if you're interested, shoot me an email. There's still some sports remaining and you can sign up for the class. Okay, so let's go into a GI bleed, right? So, how do a GI bleed present? Well, many times on Indian exams, a GI bleed is going to present as a person having, you know, a few symptoms, you know, they can have like him a themesis with a coughing bright red blood, right?

Or they can have melanin with their stool is like dark and tary. It kind of looks like asphalt on the roads. Although, don't forget, bismuth, right? Bismuth, or if you've had like activated charcoal, those can make a person's stool dark, right? Again, that's like a classic thing they can throw on an exam, right? That's not a GI bleed. For persons taking bismuth, right? And what would it take bismuth? What would it take bismuth? A people that are taking things anti-diarrhial agents, right? Like peptobismal, right? Or you've seen a person taking a bismuth in the context of quadruple therapy for peptic ulcer disease, right? Like H. Pylory, you know, remember, you can try like clarithromycin, amoxicillin, and PPI. If that doesn't work, you can try quadruple therapy, which is metronidousol, bismuth, tetracycline, and PPI, right? So, those are things that bismuth can absolutely cause black tarystops, okay? And then another thing that can present, right? They can have like hematocasia, right? This way like bright red blood is coming from the persons in us, right? They are literally pooping on bright red blood, right? So that's something you want to keep at the back of your mind, for example. Many times if a person has hematocasia, it usually means that they have a lower GI bleed, many times if you see like melanin, where they have those dark tarystops or hematemesis, usually that means they have an upper GI bleed, right? Now, the thing is, upper GI bleeds, many times, right?

Like, let me just put it this way. If you look at the whole universe of GI bleeds, right? It kind of follows the rule of thirds, right? So, two thirds of GI bleeds are upper GI bleeds, a third of GI bleeds, a lower GI bleeds. Now, why is this important to know? Because again, many people, it's kind of unfortunate if you live in a time where people just blankly memorize stuff, blankly memorize algorithms. No, the thing is, I'm telling you this, it's much easier to remember and understand an algorithm. If you know why the algorithm was set up that way in the first place, that's the truth, right? Again, I'm telling you, understanding bit memorization, any day of the week, that's one thing many people don't understand. And again, the thing is the USML Es, they are getting really good these days at writing questions where you have to reason, right? Like, for example, a common problem I see with my students, you see my students, ooh, they know the bio-stats formulas, A over A plus B, B over C plus D, blah blah blah blah blah blah blah, right? Or they've done one thing or the other where, okay, they've gotten down the formulas to assigns. The thing is, memorizing those formulas may help you for a few questions on your exams. Put the bulk of the bio-stats questions they write these days, require you to understand, right? The thing is, many times to be honest with you, even certain algorithms, I don't have to memorize them.

Because if a certain presentation comes a certain way, like, the thing I'm supposed to do makes sense. It was kind of like organic chemistry in college. You see people just memorize the mechanism, memorize the mechanism, memorize the mechanism. But when I was in college, I tried and I'm thankful to God for this, to really understand, okay, and when I understood it, if you give me a synthesis problem of, I'll see any sort for the most part, I could figure out exactly what to do. Like many of these mechanisms, I could begin to predict, this is what step one has to be, okay, this is what step two has to be. Why? Because the understanding is there, right? And those memories are more permanent in your mind because you put in effort to learn those things in the first place. But I'm going to get up by so boxing and continue, right? So the thing is, GI bleeds, most, it follows the rule of thirds. Two thirds of GI bleeds are upper GI bleeds. A third of GI bleeds are lower GI bleeds. Why does knowing this epidemiology help? It helps, because it will then make sense that most times, if you have a GI bleed problem on exams, you first want to assume they have an upper GI bleed and diagnose and treat it appropriately You rule out upper GI bleeds first before you start attending to lower GI bleeds, right? Because again, if you look at it, you have essentially plain odds, there's like a 67% chance that, oh, this GI bleeds is upper.

So it would make sense for that to be your first point of call. You always want to go to the hyperbability area first. That's what, right? So if a prison presents with a GI bleed, what do you do on NV Me exams? Again, some things I will saying this podcast are going to be different from what you find in resources. Again, remember, my podcasts are targeted to what? To the NV Me exams. I do not target my podcast to helping you answer QBAN questions correctly, because again, that's not always very useful. There are certain things that QBANX, this is something that I emphasize a lot during my review courses. If I have delicate exceptions on these, where I go over things that, okay, this is what XYZ QBANX says, this is what many resources say, this is what, there are sometimes the NV Mes don't even want to agree with the USPSTF, right? So the thing is, again, certain things you want to keep in mind, right? So just kind of keep that in mind. What I may say now may not be what you've seen elsewhere, but again, it's going to be accurate for your NV Me exam. So if a prison comes in with a GI bleed, what is the first thing you're supposed to do? The first thing you're supposed to do is you're supposed to place two peripheral I Vs. That is literally the first thing you do. You need to give you need to resuscitate those people, right? You need to give them peripheral I Vs, right? So place two peripheral I Vs, peripheral I Vs actually have a pretty high flow rate for delivering fluid to people.

It's something I kind of did the math with someone, probably a couple, couple years ago, but they do have really good flow rates shockingly, right? So you place two peripheral I Vs and then the first thing you do is you need to give them fluid. You need to give them fluid. So step one, place two peripheral I Vs, step two, give fluids and those fluids can be normal sailing, right? Again, many med students, they kind of paciferate, who should I do, lactated bringers or I'll be like, no, no, no, no, no, no, no, just give them normal sailing. That's all you need to do on exams, right? That's what you do in step two. And then, so those first two steps apply to everybody. Step one place to I Vs, step two, give normal sailing. Now, step three is where the dichotomy comes, right? The dichotomy comes. The step three actually involves giving blood, right? But you give blood based on people's circumstances. First, if the person is hemodynamically stable, then you should only give blood if the hemoglobin in the question is less than seven. The hemoglobin is less than seven and the patient is stable, give them blood. Now, if the patient is unstable, it doesn't matter what the initial hemoglobin is, you need to give them blood. I'll say if the person is unstable, the hemoglobin that they start with literally doesn't matter. Just give them blood. But again, only give blood after you've given fluids. Don't give blood before giving fluids.

If you go out of order, you will get your questions wrong on the exam, okay? So, again, step three, right? Step three, if the person is stable, right? If the person is hemodynamically stable, then look at the hemoglobin. Is it greater than seven? No blood. Is it less than seven? Give them blood. If the person is hemodynamically unstable, the hemoglobin literally does not matter. Just give them blood. That's it. That's it. Now, the fourth step you're going to, right? Again, as I've said, you assume that you have an upper GI bleed. So, the fourth step you're going to proceed to is you're going to go ahead and perform an EGD, right? EGD means a sofa go gastro-dwanoscopy, right? Because many times with an EGD, you can intervene, right? With an EGD, you can intervene. Go ahead and place that EGD. It basically helps you rule out. If the person has an upper GI bleed or a lower GI bleed, right? Because again, EGD is so far go. So, it looks at the esophagus. Gastro looks at the stomach. Buadanoscopy looks at the doggardna. Right? Because remember, we say that upper GI bleeds that bleeds proximal to the ligament of tritis, like the suspensary ligament of the doggardna. Right? Anything distal to that is a lower GI bleed. So, the thing is you're going to go ahead and perform upper endoscopy. Again, an EGD, right? If you see a bleed, then you're going to go ahead and intervene, right? But if you don't see a bleed, then you assume that you have a lower GI bleed, right?

And for president, has a lower GI bleed. Typically, your next step, one example, is to perform colonoscopy. Your next step, typically, is to perform colonoscopy. Right? So, this is the basic diagnostic pathway that you follow when you're dealing with GI bleeds. Now, one thing that occasionally makes GI bleed questions tough for people on exams is that they are certain additional things. The MBME wants you to know. Right? So, say, for example, if a person has bleeding because of esophageal varices, right? Obviously, you're going to follow the same pathway, peripheral I Vs, normal saline, if you have hemodynamiclyone stable, give them blood, right? If you have stable and the hemoglobin is over seven, don't give them blood, right? But typically, you know, you're going to do the EGD, right? Many times as you're doing that endoscopy, right? The specific therapy for people that have esophageal varices is that you're going to give them a truiltide, you're going to give them IV octuiltide. That really helps. You're also going to give them a PPI and IV proton pumping inhibitor. That really helps. And remember, as you're doing your endoscopy, you can perform sclerotherapy or banding. Either one is fine. You can do sclerotherapy or you can do banding. Either one is fine. And then those people also need IV sef triaxone, one IV fluoroquino loam, like or floxacene or nor floxacene, right? That kind of helps actually, it actually reduces mortality, right?

And it also provides some protection against spontaneous bacterial periodonitis because that can be a complication of a varicil bleed, right? So again, for people that have varicil bleeds, they're going to get that endoscopy at that time. They're going to get it that's sclerotherapy or banding, right? But in addition, you need to put them on an IV PPI, IV octuiltide, right? You're going to give them IV antibiotics, which can be a fluoroquino loam or sef triaxone, right? And again, if you've tried all these things for a varicil bleed and none of it is working, then your next step on an endemic exam is you're going to do a tips procedure, right? A transhepatic intradjogular, you know, porous systemic shunt. You basically shunt blood from the porous veins straight up to the hepatic vein, right? Because again, you want to reduce those porous pressures very rapidly. That's a procedure that's performed by interventional radiology. Okay, now if a person has peptic ulcer disease as the cause of their bleed because, believe it or not, the most common cause of upper GI bleeds is bleeding from peptic ulcer disease. Again, you're going to do an endoscopy, right? You can do some therapy to relieve the bleed, but many times what you're going to try to do for those people is you're going to give them again an IV PPI, right? You don't need to do octriol tide or an antibiotic. No, just give them an IV PPI. That's the thing that will usually help them in those circumstances.

Now, you also typically, you know, after they've been stabilized, want to go ahead and just test them for each pylori, right? People that have peptic ulcer disease just test them for each pylori so that you can treat them. Now, one thing I forgot to say with varicil bleeds is after those people have recovered, you know, they want to set them home, go ahead and put them on a beta blocker and non, like a beta blocker, like, you know, like proprylonal law, right? Or something like that. Proprylonal law, we can put them on sprylonal actin to reduce portal pressures that reduces the risk of them having a reblead, right? Again, that's high up to no for, for example, right? Again, I've talked about the diagnostic pathway. Now, one final thing I guess I would say is they can give you a special circumstance where you've resuscitated a person heavily, you've given them fluids, you've given them blood, and they are not resuscitating. They are still like crashing and burning. Let me tell you what you want to do for those people. On exams, look for the answer that says angiography with embolization. Look for the answer that says to perform angiography with embolization, right? Again, it's an interventional radiology procedure, right? The inject contrast, the Cedar bleeds, and they can clot, they can clot it off very quickly and, and emergently. That's actually a really good way to treat bleeds, especially like lower GI bleeds, right?

When a person is bleeding from like a mesenteric vessel, that's one of the best quickest ways to stop those bleeds. Again, this is stuff you want to make sure you know for exams. And one of the things I want to say is when you're giving people so much blood, right? You need to give them platelets at the same time. It's very important. You can just give people blood, like 10 units of blood and no platelets. Those people are going to get a dilution of thrombocytopenia and you're going to bleed and die. You don't want to do that, right? The thing is the body almost works in ratios. If you're giving someone a certain amount of blood, you need a certain amount of platelets to coagulate it, right? So if you're giving those people all that blood, you need to make sure that you're giving them platelets as well, right? You're giving them platelets as well. Knowing the specific conversions you don't need to, but if a person is getting a large volume blood transfusion, those people need to be getting platelets as well, right? And again, if a person is bleeding because of war-fringed toxicity, like the INR is high, then you want to use that for factor per thrombic complex concentrates to reverse it. Many times you're going to try to reverse if your INR is over 2.5. Okay, so I think I'm going to go ahead and stop here. Again, this goal of this podcast was just management.

God willing, in a future podcast, I'm going to go deeply into GI bleeds, but more from if you ask you what's the diagnosis or what's the pathophysiology on exams, right? You'll be able to answer those questions. And again, as I do at the end of every podcast, I do offer one or one to learn for all the USML exams. Step one, step two, CK, step three, preclinical, medical exams, 30th shelf exams. I have these podcasts on all the major apps, Apple podcasts, Google podcasts, Spotify, right? I have a You Tube channel, Divine Intervention, USML podcasts and videos, right? Where I post the videos that I make. And then remember, I have these review courses for step two, CK, step three, complex level two or three, right? And then I also have another website, Divine Intervention Lifelessens.com, where I put Bible-based teachings, you know, they had like 10 to 15 minute podcasts on just common problems that are faced by humanity. So if you go to Divine Intervention Lifelessens.com or even look on Apple podcasts, look for the Divine Intervention Life Lessons podcasts, you'll be able to find exactly, you're able to find those podcasts, I upload about two a week. So thank you for listening to me, have a wonderful rest of your day, God bless you, thank you.

Hematocochezia (bright red blood per rectum).

Hematemesis (vomiting bright red blood) or melena (dark, tarry stools).

Two thirds ($\approx 67\%$).

Place two peripheral I Vs and administer crystalloid fluids (Normal Saline).

Yes, because the hemoglobin is less than 7.

Colonoscopy (to evaluate the lower GI tract).

1. Place two peripheral I Vs. 2. Administer Normal Saline fluids. 3. Transfuse blood products based on stability and $\text{Hgb}$ level.

Fluoroquinolone or Ceftriaxone; to prevent spontaneous bacterial peritonitis (SBP), a common complication of variceal bleeding.

IV PP Is only. Octreotide and antibiotics are reserved for varices.

TIPS procedure (Transjugular Intrahepatic Portosystemic Shunt).

Platelets.

Prothrombin Complex Concentrate (PCC).

1. Place two peripheral I Vs. 2. Administer Normal Saline fluids. 3. Transfuse blood products based on stability and $\text{Hgb}$ level.

Fluoroquinolone or Ceftriaxone; to prevent spontaneous bacterial peritonitis (SBP), a common complication of variceal bleeding.

IV PP Is only. Octreotide and antibiotics are reserved for varices.

TIPS procedure (Transjugular Intrahepatic Portosystemic Shunt).

Platelets.

Prothrombin Complex Concentrate (PCC).