16. GI Bleeding Flashcards
When might GI bleeding lead to mortality?
What is the most important factor when assessing GI bleeding?
List possible reasons for a GI bleed?
What is the most common dx for a GI bleed?
Elderly, co-morbidity, anticoagulation
Haemodynamics (rate of loss). Variable presentation: 10% pr bleed from UGIT; 10% melaena from LGIT; 5% GIB from small bowel…
Oesophageal (peptic, infections), ulcerative/erosive (PU, DU, NSAIDs, H. pylori), portal HTN (variceal), vascular malformations (Dieulafoy lesion, arteriovenous malformation), tumours, diverticular bleed, ischaemia bowel, haemorrhoids, trauma/post-op (aorto-enteric fistula, anastamotic bleeding), post-radiation
- *Peptic ulcer** [Pic]
- NB: Mallory Weiss tear - persistent vomiting/retching causes hematemesis via an oesophageal mucosal tear*
List things to look out for/ask about in a history and physical exam of a GI bleed.
What circulation holds 20-40% of blood volume/is a major reservoir?
What is the average circulating volume of a 70kg man?
True haematemesis/melaena? Drugs (esp. anticoagulants/antiplatelets). Comorbidities (CVD, respiratory disease, hepatic/renal impairment, malignancy). General exam. CVS, pulse & BP. Evidence of chronic liver disease (leuconychia, clubbing, palmar erythema, gynaecomastia, hepatomegaly, spider naevi etc. -> caput meduse -> visible varices). PR exam
Splanchnic circulation (Coeliac, SMA, IMA) [Pic]
5L
What is the class 1 - 4 proxy of establishing the amount of blood a pt has lost?
What are the different cannula colours and flow rates?
Class 1: 10-15% loss (750ml), physiological compensation/no clinical signs
Class 2: 15-30% loss (1.5L), postural hypotension, generalised vasoconstriction
Class 3: 30-40% loss (2L), hypotension, tachycardia >120, tachypnoea
Class 4: >40% loss (3L), marked hypotension, tachycardia + tachypnoea, comatose
- *Pink** - 20g, 40ml/min
- *Green** - 18g, 75ml/min
- *Grey** - 16g, 150ml/min - EMG
- *Orange** - 14g, 300ml/min - EMG
A 54yo female presents with several episodes of melaena over the past 3 days. BP 95/60, HR 110.
What is the most important next step in managing this patient?
What blood tests would you do for a GI bleed?
How is endoscopy useful in a GI bleed?
Protect airway + high flow O2, IV access (2x grey or green cannulas), fluids (2L - rapid resus), blood product transfusion. These will rapidly correct haemodynamics. Also insert catheter and monitor urine output, organise CXR, ECG, check ABG…
FBC, U+E, LFTs, coag screen, group & save/X match
Done after resus within 4h of suspected variceal haemorrhage, or when bleeding is ongoing within 24h of admission.
It can: ID bleeding sites, estimate risk of re-bleeding, aid treatment e.g. sclerotherapy, variceal banding to prevent re-bleeding. 80% ulcers and 60% varices stop bleeding spontaneously
What is the Rockall score, and how is it useful?
What is another score that can be used?
Stratifies risk of death before and after gastroscopy, aids in deciding when to perform gastroscopy. [Pic] An initial score >6 is an indication for surgery. Risk of rebleed increases as Rockall score increases
Glasgow Blatchford Score: asesses liklihood a pt with a UGI bleed will need a medical intervention e.g transfusion or endoscopy. If = 0, admission can be avoided i.e. Hb ≥ 130g/L (male) or ≥ 120g/L (female), systolic BP ≥ 110mmHg, pulse <100/min, urea <6.5mmol/L, no melaena or syncope + no past/present liver disease or heart failure
What is the inital medical management of an upper GI bleed?
How can warfarin be reversed? (3 ways)
Would you stop warfarin in pts with prosthetic valves having a major GI bleed?
What imaging proceedure should all pts with a GI bleed have ASAP?
Correct: platelets <50, clotting when INR >1.5, NOAD (idarucizumab - reverses dabigatran anticoagulant), reverse clopidogrel/aspirin with plts. Start oral PPI e.g. 30mg lansoprazole. Tranexaemic acid (antifibinolytic)
IV Vit K, human prothrombin complex (2,3,9,10), FFP. Speak to haematologist
Yes! Reverse with FFP if necessary
Endoscopy - can be used to treat active bleeding/prevent re-bleeding
What prophylactic abx could be given for a variceal bleed as part of initial medical management?
Why might terlipressin (lysine vasopressin) be given?
What 3 things could endoscopic therapy be used to do for bleeding oesophageal varices?
Cephalosporin, quinolone, augmentin
Mesenteric/splanchnic vasoconstrictor, decreases portal venous inflow. Give straight away if varices likely
- *1. Sclerotherapy** - needle injection of sclerosant into varix. 70% haemostasis. 45% re-bleed
- *2. Banding** - elastic ring around enlarged vein. >80% haemostasis. 27% re-bleed
- *3. Sengstaken tube** - only for intubated pt, stiffen tube with wire, v. rarely need oesophageal balloon. 90% effective [Pic]
- Stents can also be used to treat acute oesophageal variceal bleeding - more effective but more ££*
What is the most common cause of small bowel bleeding?
List some tools that can be used to investigate.
Why are PPIs given post-endoscopy?
When would you resort to surgery?
Angiodysplasia (small vascular malformation)
New: video pill and endoscopy, balloon enteroscopy
CT angiography/interventional angiography
Low pH activates pepsin -> lyses clot and inactivates platelets. PPI will thus produce a higher pH = lower acidity = more stable clot and more effective platelets = environment around ulcer promotes healing
10% of bleeding due to peptic ulcers - can’t treat with scope. Surgery if uncontrolled further haemorrhage, failed endoscopic tx (2x). Also older pts tolerate hypovolaemia poorly = earlier surgery?
How would you discharge/follow up an upper GI bleed due to gastric ulcer?
How would you discharge/follow up an upper GI bleed due to variceal bleed?
2nd look endoscopy at 24-48hrs if stable? (Not if on PPI infusion).
H. pylori eradication
Re-start anti-platelet tx? (aspirin + maintenence PPI)
If gastric ulcer hasn’t healed in 6-8w, consider cancer
Beta-blockers for varices - propanolol (decreases pressure in portal/systemic circulation)
Re-banding for varices until obliterated (if can’t tolerate B-blocker)
TIPS proceedure (transjugular intrahepatic portosystemic shunt)
All survivors evaluated for liver transplant - best outcome
