Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

GI Pathology > 12. Acute GI Bleeding > Flashcards

12. Acute GI Bleeding Flashcards

1
Q

Define upper and lower GI bleeding.

A

Upper GI: Bleeding from oesophagus, stomach or duodenum. Proximal to ligament of Trietz.
Lower GI: Bleeding distal to duodenum (jejunum, ileum, colon). Distal to ligament of Trietz.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Where is ligament of Trietz found?

A

The ligament of Treitz (suspensory ligament of the duodenum) marks the boundary between the upper and lower gastrointestinal (GI) tracts. It arises from the right crus of the diaphragm and suspends the duodenojejunal flexure.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the clinical signs of upper GI bleed?

A
  • Haematemesis (the vomiting of blood)
  • Melaena (passage of black tarry stools, black colour due to blood altered by passage through the gut).
  • Elevated Urea. Digested blood: haem -> urea
  • Associated with dyspepsia, reflux, epigastric pain
  • Non-steroidal anti-inflammatory use
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the clinical signs of lower GI bleed?

A
  • Fresh blood/clots
  • Magenta stools
  • Normal urea (rarely elevated if proximal small bowel origin)
  • Typically painless
  • More common in advanced age
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the causes of acute upper GI bleed?

A

In all areas cause = ulcers. Oesophagitis/ gastritis/ duodenitis tend to bleed in context of abnormal clotting.

Oesophagus: Oesophageal ulcer, Oesophagitis, Oesophageal varices (dilated sub-mucosal veins), Mallory Weiss Tear, Oesophageal malignancy

Stomach: Gastric ulcer, Gastritis, Gastric varices
Portal hypertensive gastropathy, Gastric malignancy (may be under ulcer), Dieulafoy, Angiodysplasia (may be acute or chronic)

Duodenum: Duodenal ulcer, Duodenitis, Angiodysplasia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the risk factors for peptic ulcers?

A
  • Helicobacter pylori: produces urease -> ammonia produced -> buffers gastric acid locally => increased acid production
  • NSAIDs/Aspirin: prostaglandin production -> reduced mucus and bicarbonate excretion => reduced physical defences
  • Alcohol excess
  • Systemic illness – “Stress ulcers”
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

If gastric ulcer is identified, why is it important to repeat endoscopy 8 weeks after?

A

Gastric ulcers may sit over a gastric carcinoma, repeat endoscopy so the malignancy is not missed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Which syndrome causes poor healing duodenal ulcer?

A

Zollinger-Ellison syndrome (gastrin-secreting pancreatic tumour)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the risk factors for gastritis and duodenitis? Under which conditions do they tend to cause a bleed?

A
  • Similar risk factors to gastric and duodenal ulcer
  • Tend to bleed in context of impaired coagulation:
    > Medical conditions
    > Anti-coagulants (warfarin, rivaroxaban, apixaban, dabigatran, LMWH)
    > Anti-platelets (clopidogrel, ticagrelor)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are the risk factors for oesophagitis? What kind of medication can exacerbate bleeding?

A
  • Acid reflux (reflux oesophagitis)
  • Hiatus hernia
  • Alcohol
  • Bisphosphonates
  • Systemic illness
    More likely to have significant bleeding if on anti-platelet (clopidogrel, ticagrelor) or anti-coagulation (warfarin, rivaroxaban, apixaban, dabigatran)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Varices:

  1. Define it.
  2. What causes it?
  3. Where are they most common?
  4. What can precipitate bleeding in patients with varices?
A
  1. Abnormally dilated collateral vessels
  2. Secondary to portal hypertension, usually due to liver cirrhosis
  3. Most common = Oesophageal (90%), Gastric (8%), Rectal and splenic (rare)
    Lower oesophagus most affected as these veins drain into gastric veins which in turn drain into portal vein. Upper oesophagus veins drain into azygous veins so have no part in the development of varices.
  4. Increases in portal pressure (eg infection/drug use/alcohol use) can precipitate bleeding.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What kind of malignancy cause upper GI bleeding?

A
  1. Oesophageal cancer:
    - May have dysphagia /weight loss history
    - Typically “ooze”
  2. Gastric cancer:
    - Can present as an ulcer
    - GU needs interval endoscopy for healing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Mallory-Weiss tear:

  1. Where does it normally occur?
  2. What causes it?
  3. How is it treated?
A
  1. Linear tear at oesophago-gastric junction
  2. Follows period of retching/vomiting (which could be due to alcohol, bulimia, food poisoning etc.)
  3. Endoscopic treatment (Up to 10% require it)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What causes Diuelafoy lesions?

A

Submucosal arteriolar vessel eroding through mucosa that can bleed.
Commonly affects gastric fundus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Angiodysplasia:

  1. Define it?
  2. Which condition is it associated with?
  3. Bleeding is often precipitated by?
A
  1. Angiodysplasia = presence of an arteriovenous malformation (abnormal connection between an artery and vein) located within the submucosa. Can occur anywhere in the GI tract. Friable and bleeds easily. Frequent cause of chronic occult or overt occult bleeding.
  2. Associated with chronic conditions including heart valve replacement. Angiodysplasia in the presence of aortic stenosis is called Heyde’s syndrome.
  3. Bleeding often precipitated by anticoagulants/ antiplatelets
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What investigations would you perform if upper GI bleed suspected?

A

Upper GI Endoscopy: Both diagnostic and therapeutic.

Within 24 hours – sooner if unstable (NICE 2012)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the colonic causes of acute lower GI bleeding?

A
  1. Anatomical: Diverticular disease
    - Anorectal pathology (e.g. anal fissures, haemorrhoids)
  2. Vascular: Acute mesenteric ischaemia
    - Angiodysplasia
  3. Neoplastic: colonic polyps or carcinoma (malignancy). Often preceding lower GI symptoms. Very rare to see life-threatening bleeding
  4. Radiation enteropathy/proctitis
  5. Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)
18
Q

How is lower GI bleed diagnosed?

A
  1. Lower GI endoscopy:
    - Flexible sigmoidoscopy – if large volume views limited
    - Colonoscopy – requires preparation
  2. CT Angiography
19
Q
  1. Diverticulosis is characterised by what?
  2. Compare diverticulosis and diverticulitis.
  3. T/F: In majority of cases the bleeding is self-limiting.
A
  1. Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch.
  2. Diverticulosis refers to the presence of multiple diverticuli within the bowel whereas diverticulitis refers to inflammation of a diverticulum, multiple diverticuli or whole segments of bowel (typically due to infection). Diverticulitis can lead to the formation of abscesses and complications including fistulae and bowel perforations.
  3. True. In 75% cases = self limiting. Risk of recurrence though.
20
Q

Case: You’re a GP and your next patient is a 24 year old female who usually tends to constipation presenting with a 24 hour history of painless fresh red bleeding per rectum which occurred following a period of straining. What is the diagnosis? How is it treated?

A

Diagnosis: haemorrhoids. These are enlarged vascular cushions around anal canal. Painful if thrombosed or external. Association with straining/constipation/low fibre diet. Common, rarely serious bleeding.

Treatment: elective surgical intervention

21
Q

How is angiodysplasia treated?

A

Treatment with Argon Phototherapy, medication including tranexamic acid, thalidomide.

22
Q

Ischaemic colitis:

  1. What causes it?
  2. How does it present?
  3. What are the complications of it?
  4. How does the mucosa looks on investigation?
  5. In which age is it normally common in?
A
  1. Disruption in blood supply to colon. Affects areas according to blood supply, typically descending/sigmoid colon.
  2. Crampy abdominal pain and sudden bleeding
  3. Complications include gangrene and perforation
  4. Dusky blue, swollen mucosa
  5. Over 60’s
23
Q

Radiation proctitis:

  1. What causes it?
  2. How does it present?
  3. What is the treatment?
A
  1. Exposure to ionizing radiation as a part of radiation therapy for e.g. cervical and prostate cancer causes inflammation and damage to the lower parts of the colon.
  2. Crescendo PR bleeding over months/years. May be dependent on blood transfusions due to chronic loss.
  3. APC, Sulcrafate enemas, Hyperbaric oxygen
24
Q

Inflammatory bowel disease:

  1. What are they symptoms of it?
  2. How is it treated?
A
  1. Slower onset with associated diarrhoeal symptoms

2. Treatment depends on extent/severity

25
Q

If no colonic cause is found and upper GI bleeding excluded need to consider small bowel origin. Name some of these small bowel causes.

A
  • Meckel’s diverticulum
  • Small bowel angiodysplasia
  • Small bowel tumour/GIST
  • Small bowel ulceration (NSAID associated)
  • Aortoentero fistulation – following AAA
26
Q

How would you investigate small bowel disease?

A
  • CT angiogram
  • Meckel’s scan (Scintigraphy)
  • Capsule endoscopy
  • Double balloon enteroscopy
27
Q

What is Meckel’s diverticulum? How is it diagnosed?

A

Meckel’s diverticulum is an outpouching or bulge in the lower part of the small intestine. The bulge is congenital (present at birth) and is a leftover of the umbilical cord. 2% population, 2ft from ileocaecal valve, 2 inches long.
Nuclear Scintigraphy is diagnostic

28
Q

How is gastrointestinal haemorrhage managed initially?

A

A. Airway
B. Breathing
C. Circulation: Wide bored IV access => IV fluids, blood transfusion.
- Urgent blood samples to lab: FBC, U&Es, LFTs,
- Coagulation, blood group and save/ cross match
- Blood transfusion if Hb<7g/dl or ongoing active bleeding: Consider major haemorrhage protocol. Evidence that transfusing Hb>10g/dl has worse outcomes
- Catheter
- ?? Tranexamic acid
D. Disability
E. Exposure

29
Q

After performing initial management, what else would you do for a patient with gastrointestinal haemorrhage?

A
  • Risk stratification for placement in HDU
  • Endoscopy once stable (within 24 hrs), sooner if unstable
  • Withhold/reverse contributory medications as able (restart them once homeostasis achieved): Vitamin K or Factor IX complex (Beriplex) if on warfarin
  • Blood products if ongoing bleeding: IV Platelets if < 50. FFP if INR or APTT > 1.5x normal range or Cryoprecipitate if fibrinogen < 1.5 g/L
  • Specific medications
  • Consider CT angiography/interventional radiology/surgical interventions as appropriate
30
Q

What happens if the patient loses significant amount of volume from bleeding etc.?

A

Patient may go into shock (circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia). Shock can be classed in 4 stages depending on the amount of fluid loss.

31
Q

What are the signs of haemorrhagic shock?

A
  • a high respiratory rate (tachypnoea)
  • a rapid pulse (tachycardia)
  • anxiety or confusion
  • cool clammy skin
  • low urine output (oliguria)
  • low blood pressure (hypotension)
32
Q

Name few ways of stratifying upper GI bleeding risk.

A
  1. Rockall score: designed principally to predict death, but also used to predict re-bleeding
  2. Blatchford Score: used to decide who needs endoscopy (scores ≥6 associated with a greater than 50% risk of needing an intervention). Based on:
    Pre-endoscopy score:
    - Blood urea (mmol/L)
    - Haemoglobin for men (g/L)
    - Haemoglobin for women (g/L)
    - Systolic blood pressure (mm Hg)
    - Other markers: Hepatic disease, Cardiac failure, melaena, syncope.
33
Q

Name few ways of stratifying lower GI bleeding risk.

A

No validated scoring systems
1. Age: acute lower GI bleed occurs most often in the elderly. Relationship with age and mortality less well defined than UGIB

  1. Co-morbidity - Presence of 2 co-morbid conditions doubles the chance of a severe bleed
  2. Inpatients - Inpatients who have rectal bleeding have a 23% mortality compared to 3.6%
  3. Initial shock and frank rectal bleeding are important predictors of subsequent severe bleeding
  4. Drugs - Patients taking Aspirin and NSAIDs are at increased risk of lower GI bleeding
34
Q

How are peptic ulcers managed?

A
  1. Proton pump inhibitors
  2. Endoscopy with endotherapy: Identify those at high risk of further bleeding. Endoscopic therapy to pathology. Therapy includes: Injection (Adrenaline 1:10000), Thermal (contact – “gold probe”), Mechanical
    (clip) , Haemospray. Combination therapy most effective (adrenaline + thermal or clips).

If bleeding uncontrollable endoscopically then perform:

  1. Angiography and embolization
  2. Laparotomy
35
Q

How are varices managed?

A
  1. Endotherapy:
    - Oesophageal: Band ligation, Glue injection
    - Gastric: Glue injection
    - Rectal: Glue injection
    Ideally intubated for airway protection
  2. IV Terlipressin: Vasoconstrictor of splanchnic blood supply. Reduces blood flow to portal vein, reducing portal pressures. Mortality reduced 32% to 12%
  3. IV Broad spectrum antibiotics: often precipitated by systemic infection
  4. Correct coagulopathy

When bleeding uncontrolled at endoscopy perform:
- Sengstaken-Blakemore tube Transjugular intrahepatic porto-systemic shunt

36
Q

Case: 53 year old male brought to A&E by ambulance having collapsed at home when attempting to stand up having used the toilet. He reports passing black, loose, sticky bowel motions for preceding 24 hours.
What might be the cause?

A

Upper GI bleed.

37
Q

What kind of questions may be useful in establishing the diagnosis (e.g. upper GI bleed)?

A

Is he on any medications?
Has he had any abdominal pain?
Has there been any change in his weight recently?
What is his alcohol consumption per week?
Does he take any painkillers?

38
Q

An injecting drug user presents to A&E with fresh haematemesis and collapse. On examination you notice a mass in his left upper quadrant. What is the most likely diagnosis?

A
  • Liver cirrhosis secondary to chronic hepatitis C

- LUQ mass: enlarged spleen due to portal hypertension, portal hypertension is cause of varices.

39
Q

Define haematochezia.

A

Passage of fresh or altered blood per rectum – may be from upper GI cause as “fast transit” or lower GI.

40
Q

Define Magenta stools.

A

Red-purple stools, typically from right colon or distal small bowel.

41
Q

An 80 year old male presents with a 12 hour history of magenta stools, he is pale and clammy. Heart rate 98 bpm, BP 140/100, resp rate 22 bpm. When he stands he is dizzy and looks unwell. Hb 10g/dl, Urea 4mmol/L. What is the 1st treatment?

  1. IV fluids
  2. Blood transfusion
  3. Endoscopy
  4. Embolisation
  5. Laparotomy
A

IV fluids

GI Pathology (20 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions