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GI > 2-anaemia & GI bleeding > Flashcards

2-anaemia & GI bleeding Flashcards

1
Q

what is anaemia?

A

reduced total red blood cell mass
= defined as low concentration ofhaemoglobinin the blood. This is the consequence of an underlying disease, not a disease itself

→First, you look at haemoglobin, if this is low →look at MCV

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2
Q

what are anaemia surrogate markers?

A

= what you measure to assess type & severity of anaemia
- haemoglobin concentration
- haematocrit = proportion of red cells in blood, in %
- also mean corpuscular volume (MCV) = measurement of the average volume or size of red blood cell

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3
Q

what are the surrogate markers in steady state in adult male + female?

A

adult male:
- haemoglobin = <130g/L
- haematocrit = <38%

adult female:
- haemoglobin = <120g/L
- haematocrit = <37%

MCV between 80-100 for both

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4
Q

what are symptoms of anaemia?

A
  • mainly fatigue but especially if chronic it’s often asymptomatic
  • weakness
  • pale skin
  • rapid heartbeat
  • cold
  • chest pain
  • dizzy
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5
Q

what are haematynics?

A

building blocks of red blood cells e.g. folic acid, iron, vit B12

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6
Q

what is mean corpuscular volume?

A

average volume of red blood cell

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7
Q

what does low MCV mean?

A

MCV = mean corpuscular volume

low (microcytic) = important reason to remember = problems with hemoglobinization (lack of iron)

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8
Q

what does high MCV mean?

A

MCV = mean corpuscular volume

high (macrocytic) = main to remember is problems with maturation = lack of folic acid or b12

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9
Q

what does normal level MCV mean?

A

normocytic = can be due to anaemia of chronic disease

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10
Q

what are dietary sources of iron haematinic?

A

= animal meat (40% haem iron Fe2+, 60% non haem iron fe3+)

= plants (100% non haem iron Fe3+) e.g. beans, lentils, rice, broccoli, spinach, nuts , asparagus

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11
Q

what are dietary sources of folate?

A

= Leafy greens, beans, peanuts, fresh fruit, whole grains, seafood, eggs

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12
Q

what are dietary sources of b12?

A

= fortified foods (eg breakfast cereals, nutritional yeast), dairy, fish, meat, poultry, eggs

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13
Q

what is 2 step process to absorption of b12?

A

intrinsic factor binds to B12 and carries down small intestine to where it’s absorbed in distal ileum

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14
Q

what can go wrong with gastric causing malabsorption of haematinics?

A
  • patient develops antibodies of cells that impair function of intrinsic factor
  • may have low gastric acid (which is important for releasing b12 bound to food) = could have low acid because gastritis (inflammation leading to change in mucosal cells and eventually atrophy), proton pump inhibitors, gastrectomy (removing stomach reduces acid produced)
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15
Q

what are small intestine problems that can cause malabsorption of b12?

A
  • secondary bacterial overgrowth that utilise b12 for own metabolism before chance we absorb
  • surgical resection of terminal ileum (particularly happens in crohns disease) which means can lose ability to absorb b12 and would require injection of b12
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16
Q

where is folic acid absorption?

A

jejunum

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17
Q

what is result of folic acid deficiency?

A

Deficiency may produce megaloblastic anaemia (type of macrocytic anaemia)
- teratogenic effects = harmful effects that inadequate levels of folic acid can have on the developing fetus
(folate important in pregnancy, without it = foetal abnormalities)

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18
Q

where is iron absorption?

A

in stomach iron dissolves and binds to mucoprotein (carrier)
-then absorbed in duodenum and proximal jejunum

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19
Q

what is process of iron absorption?

A
  • ascorbic acid (secreted in gastric juice) reduces ferric (Fe3+) to ferrous (Fe2+)
  • then ascrobic ascid turns ferrous into soluble iron-ascorbate chelate complex which makes transport & absorption easier
  • then absorbed in duodenum & proximal jejunum
  • once in enterocytes, can be stored as ferritin (type of Fe3+) or transported in circulation for metabolic purposes
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20
Q

what is transportation of iron once in plasma?

A

iron enters plasma in ferrous form (Fe2+) and oxidised immediately to ferric form (Fe3+) and then Fe3+ is in complex with transferrin (a carrier glycoprotein) which can be stored in mucosal cell as ferritin or to plasma

  • Fe2+ oxidised to Fe3+ as either ferritin or transferrin
  • ferritin = where iron can be stored and transferrin = what can transport iron to other areas of body
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21
Q

what is ferrous iron and what is ferric iron?

A

ferric = Fe3+ (remember by c 3rd of alphabet)
ferrous = Fe2+

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22
Q

what pH environment is required for non haem iron absorption?

A

non haem iron needs acid environment for absorption

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23
Q

what can cause malabsorption in iron deficiency anaemia?

A

malabsorption by non acidic environment:
- Chronic gastritis and secondary achlorhydria‏ (pathological lack of acid)
- Proton Pump Inhibitor therapy (long term use)
- Small bowel disease like coeliac disease = allergy of gluten (component of wheat) - damages small intestine, Crohn’s disease

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24
Q

what are causes of blood loss causing iron deficiency anaemia?

A
  • heavy periods
  • Usually GI bleeding (consider menorrhagia, haematuria)
  • ulcer (including those caused by Non-Steroidal Anti-Inflammatory Drugs)
  • neoplasia (colon cancer)
  • inflammatory bowel disease
  • angiodysplasia
25
Q

how can you tell if GI bleeding top or bottom?

A

vomiting blood(haematemesis) = top

blood out rectum = bottom

26
Q

what is ligament of treitz? and why is it important?

A
  • band of tissue that supports + anchors duodenum duodenojejunal flexure (junction between the two) and helps move contents along GI tract
  • ligament’ can help in determining if bleeding above or below duodenojejunal flexure - above ligament is upper GI and below ligament is lower GI bleeding
27
Q

can there be GI blood loss without symptoms?

A

yes = small volume GI blood loss can occur without any symptoms or signs of bleeding (5ml a day would be 2.5mg iron and might go unnoticed)

5ml bleeding = amount that isn’t enough to cause visible symptoms

28
Q

what can result from occult of GI blood loss

A

(5ml a day would be 2.5mg iron and might go unnoticed)

  • this can outstrip the maximum dietary iron absorption of iron and result in microcytic anaemia (lack of iron)
29
Q

what are causes of occult of GI blood loss? (amount of bleeding with no symptoms)

A
  • neoplasia = locally advanced colonic adenocarcinoma
  • angiodysplasia - arterio-venous malformations on mucosal surface (abnormal blood vessels prone to rupture)
30
Q

what are symptoms of acute upper GI bleeding?

A
  • coffee ground vomit = traces of altered blood (unlikely it’s significant bleeding)
  • fresh blood - haematemesis
  • dark black tarry faeces (malaena) with characteristic odour
31
Q

what are causes of acute upper GI bleeding?

A
  • gastric ulcer (caused by NSAIDs or h.pylori infection) →usually in antrum (before pylorus)
  • gastric erosions by NSAIDs or alcohol
  • oesophagitis (inflammation of oesophagus) →might expect coffee ground vomiting
  • mallory weiss tear = along lower end of oesophagus next to stomach during vomiting as when retching stomach goes up into oesophagus →if repeatedly can get tear
  • varices = caused by liver disease + portal vein thrombosis
32
Q

what is difference between gastric erosion + ulcer?

A

erosion vs ulcer →ulcer 3mm or bigger (erosion less than 3mm)

33
Q

what is glasgow blatchford score?

A

identifies likelihood of endoscopic intervention (low score = unlikely need endoscopic intervention)

  • depends on how much bleeding and patient history, clinical examination and blood results
34
Q

what is clinical examination findings for acute upper GI bleeding?

A
  • tachycardia (pulse >100/min)
  • hypotension
  • stigmata of liver disease e.g. jaundice, finger clubbing

(think like symptoms of hpovolaemic shock)

35
Q

what is blood results for upper GI bleeding?

A

2 components of blood test →haemoglobin + blood urea (waste product formed in the liver as a result of protein metabolism)

urea + creatinine go hand in hand when looking for dehydration →rise in urea + creatinine when dehydrated, when GI bleeding get isolated rise in blood urea and no change in creatinine

  • haemoglobin low
36
Q

why is blood urea important severity marker for bleeding?

A

blood urea important for severity as blood full of protein if blood in upper GI tract as would go into small intestine and get broken up into urea (bigger urea = bigger volume of blood patient lost + absorbed)

37
Q

what is clot formation and what can disrupt it?

A

the body’s clotting cascade is actively stopping the bleeding!

→however in stomach, clot dissolution (stopping clot) can occur due to gastric acid + pepsin

  • acid weakens clot and pepsin degrades fibrin (along with normal function of protein breakdown)
38
Q

what are clinical methods to stop bleeding?

A
  • Injection tamponade (vasoconstrictor injected to promote haemostasis)
  • Heater probe coagulation (cautery = heating to vessel causing coagulation & sealing)
  • Clips (mechanical)
  • Haemospray (procoagulant - haemostatic agent promoting clotting)
39
Q

why does acid inhibition treat GI bleed and what drug can be used?

A

omeprazole = omeprazole stabilises rebleeding by not allowing acid to interfere (acid weakens clot so want to stop it)

40
Q

after first intervention to prevent GI bleed, what should be monitored and what needs to be done if bleed continues?

A
  • monitor blood tests →want to see urea to come down and haemoglobin to stabilise
  • also want to see black stool stop
  • when these changes don’t happen then patient still bleeding so have to interfere again by interventional radiology or surgery
41
Q

where do right and left gastric arteries run?

A

run along lesser curve and anastamose together

42
Q

what does gastroduodenal artery supply?

A

supplies pylorus and proximal duodenum

43
Q

where do right + left gastro-omental arteries run?

A

run along greater curve and anastamose together

44
Q

what stomach arteries are important to know for bleeding?

A

left gastric + gastroduodenal are important as the lesser curve + pylorus are more common areas for ulcers

  • radiographers inject contrast into arteries to identify bleeding point and then embolism with metal coils to encourage clotting
45
Q

other than stomach - what organ is major cause of upper GI bleed?

A

liver

46
Q

what is portal hypertension?

A

high pressure in portal system - blood tries to find a way round the collaterals

47
Q

what are the 3 collateral pathways relevant to bleeding? (liver - uppper GI)

A
  1. Oesophageal and gastric venous plexus: Oesophageal, Gastric Varices (Portal Hypertensive Gastropathy)
  2. umbilical vein from the left portal vein to the epigastric venous system →Caput Medusa
  3. the hemorrhoidal venous plexus →Rectal varices
48
Q

how does portal hypertension lead to bleeding?

A

portal hypertension causing anastamoses (+ the collaterals) to become engorged and varicosed and then rupture causing bleeding

49
Q

what are treatments for acute variceal bleeding?

A
  • resuscitation = spiral of death (give blood)
  • Pharmacological therapy = terlipressin (reduces blood flow to portal vein)
  • Endoscopy = Banding
  • Failed therapy = TIPSS (shunt to reduce pressure)
50
Q

what is balloon tamponade?

A

can be temporary treatment for bleeding = need to swallow contraption then fill balloon with water and put pressure to stop bleeding

51
Q

what is TIPPS?

A

Transjugular Intrahepatic Portosystemic Shunt

create shunt in liver connecting portal system + systemic system →pass into internal jugular, access liver through hepatic veins →bore a channel through liver tissue into portal vein →pass down shunt to make permanent passage into liver which relieves pressure in liver by creating fresh channel

= leaves permanent shunt in liver, very effective in short term

52
Q

what bloods show acute lower GI bleeding?

A

if blood urea normal = confident that lower GI bleed as no blood absorbed in small intestine

53
Q

how do you settle lower GI bleeding?

A

mostly settle spontaneously with bodies blood cascade
but can rarely involve endoscopic and if uncontrolled bleeding then radiological therapy to embolize

54
Q

what are 2 most common causes of lower GI bleeding? and what are others?

A
  • 1st = diverticulosis with bleeding
  • 2nd = ischaemic colitis

others - haemorrhoids, colorectal cancer, angiodysplasia, meckel’s diverticulum (genetic thing)

55
Q

what is diverticular bleed?

A
  • commonly in sigmoid colon
  • large volume of blood, frequently with clots
  • painless, more common in elderly
  • frequently light headed
  • 80% settle on their own
56
Q

simply - what is brief mechanism of diverticular bleed?

A

pelvic stool wedges that erodes mucosa and punctures artery so arterial bleeding
= small pouch-like protrusions that can develop in the wall of sigmoid colon

57
Q

what are symptoms of ischaemic colitis?

A

cramping lower abdominal pain followed by blood + loose stool

→settles spontaneously because such good collateral blood supply in gut

58
Q

what is classic presentation of ischaemic colitis?

A
  • elderly
  • underlying vascular disease
  • drop in blood pressure

GI (56 decks)

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