2) GI system 1 Flashcards
ACUTE UPPER GI BLEED
- most common causes? 5
- other causes? 3
= Peptic ulcer disease (35-50%)
= gastroduodenal erosions (8-15%)
= oesophagitis (5-15%)
= mallory-weiss tear (15%)
= varices (5-10%)
- upper GI malignancy
- vascular malformations
- swallowed blood (eg from facial trauma, nose bleed or haemoptysis)
UPPER GI BLEED
- risk factors? 3
- classes of drugs which increase risk? 5
- alcohol dependence (all, but especially varices)
- liver disease (same as above)
- lots of vomiting from eg morning sickness (mallory-weiss)
(also other risk for the relevant causes - eg RFs for PUD)
DRUGS
- anti-coagulants (LMWH, warfarin, DOAC)
- anti-platelets (aspirin, clopidogrel)
- NSAIDs
- steroids
- SSRIs
UPPER GI BLEED
- name of two scores used?
- what is each used for?
BLATCHFORD SCORE
- need for admission and endoscopic intervention
(0-1 = discharge w/ OP OGD)
ROCKFALL SCORE
- predicts risk of Re-bleeding and mortality post-endoscopy
(higher the score, worse the mortality)
UPPER GI BLEED
- 2 presentations of blood in the vomit?
- 2 presentation of blood in stools?
- other clinical signs? 2
- clinical signs and vital signs that may indicate large amount of blood loss?
Basically signs of SHOCK!
initally
- light headed
- SOB
- anxious
Peripherally shut down
- Cold
- ↓CRT
- ↓UO (<0.5ml/kg/hr)
- reduced GCS
THEN
- Dyspnoea (due to anaemia) – indicates large bleed
- Tachycardic > 100bpm (compensate for ↓BP)
↓GCS
- Hypotensive <90/60 → dizzy and syncope (nb may only be postural in young people)
LARGE UPPER GI BLEED
- principle of assessment + management? 1
- bloods to take? 6 (and possible findings)
- other things to do / give under ABC (2 do, 3 consider)
A-E approach
BLOODS
- FBC (low or normal Hb, takes time to drop!)
- U+E (raised urea out of proportion to Creat indicates massive bleed)
- LFT
- Clotting
- VBG/ABG
- cross-match OR group & save
A+B
1) airway patent and give O2 (if low)
C
2) Get IV access (ideally two) AND give fluid challenge
3) CONSIDER giving blood (O neg is immediate, type specific 20 mins, corss match 45 mins) - major haemorrhage protocol if massive!
4) CONSIDER giving vit K +/-berliplex (if active bleed on warfarin)
5) monitor urine output and CONSIDER catheterising
LARGE UPPER GI BLEED - DISABILITY + EXPOSURE:
- what to make sure to do as part of abdo exam?
- are patients allowed to eat + drink?
- what 2 scores to calculate?
- who to refer to? 1 (+ when to call)
DRE
- essential!!
- to see if any melaena (nb be aware of iron supplements!)
patients should be NBM (at least for 24hrs if big bleed)
calculate:
-BLATCHFORD SCORE
- need for admission and endoscopic intervention
ROCKALL SCORE
- predicts risk of Re-bleeding and mortality post-endoscopy
refer to GASTRO REG
- depnds on the size of the bleed! - if massive + active, call before even assess - if controllable, call after A-E
- ask what drugs (if any to give and whether to give blood)
nb also call anaesthetist if struggling to protect airway
LARGE UPPER GI BLEED
medication to give to ALL large upper GI bleeds? 1
- medication to consider giving if variceal cause? 2 (main CI to one of these)
ALL
- OMEPRAZOLE (80mg stat IV, then 8mg/h for 72hrs) - nb normally start this after OGD
VARICES
- TERLIPRESSIN IV (decreases portal pressure, CI = IHD)
- prophylactic ANTIBIOTICS (for SBP)
(nb don’t start these drugs until spoken to gastro reg)
LARGE UPPER GI BLEED
- what intervention do all need? (+time frame)
- purpose of this intervention
- specificmanagement options within this intervention for variceal bleeds?
- 2nd line management options if bleed too big?
need ENDOSCOPY (OGD)
- within 4 hrs if suspect varices
- within 12-24hrs if shocked on admission or significant co-morbidity
purpose:
1) find CAUSE of bleed
2) TREAT bleed if still active
varices = SCLEROTHERAPY (inject into varices to ‘sclerose’ them) OR banding
IF V BIG BLEED
1) balloon tamponade during OGD
2) open surgery
nb other treatment options during OGD (don’t learn off by heart):
use either mechanical (clips) w/ or w/o adrenaline; thermal coag w/ adrenaline, fibrin or thrombin w/ adrenaline, haemospray (useful for ulcers)
If no site of bleeing found on OGD fopllowing upper GI bleed, what could this mean? 4
A) Bleeding site MISSED on endoscopy
B) Bleeding site HEALED prior to endoscopy (eg mallory-weiss or dieulafoy’s)
C) blood had been SWALLOWED (so not GI bleed)
D) Site of bleeding is DISTAL to where endoscopy done (eg meckel’s diverticulum, colonic site)
VARICEAL BLEEDING
- primary prevention options? 2
- secondary prevention options?
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10
Q
VARICEAL BLEEDING
- primary prevention options? 2
- secondary prevention options?
A
PRIMARY PREVENTION
- propranolol (mainstay!)
- repeat endoscopic banding
don’t give propranolol acutely if bleeding as may make worse!
SECONDARY PREVENTION (ie following bleed)
- endoscopic banding
- TIPS (transjugular intrahepatic portosystemic shunt – joins hepatic + portal vein)
What complication should you observe for for all large GI bleeds?
what signs may this present with? 5
other possible complication of all GI bleeds?
RE-BLEED
continuous monitoring of vitals
signs of re-bleed
- rising pulse rate
- falling JVP
- decreasing hourly urine output
- further haematemesis (or melaena)
- fall in BP (late sign) + drop in GCS
40% of patients who re-bleed will die!! - make sure monitor appropriately to catch early!
other complication = ASPIRATION pneumonia! (develops later!)
VARICEAL BLEEDING
- prognosis following 1st bleed?
- specific complication associated with variceal bleeds? 1
Following 1st variceal bleed – 60% re-bleed in 1st year
complications of variceal bleeds:
- Spontaneous bacterial peritonitis (SBP)
(also re-bleed + aspiration pneumonia - as with all GI bleeds)
TYPICAL PRESENTATION of causes of OESOPHAGEAL BLEED:
- oesophagitis?
- oesophageal cancer?
- mallory-weiss tear?
- varices?
(incl amount + appearance of blood AND associated symptoms + other features of history)
also if tend to stop spontaneously or not
OESOPHAGITIS
- small volume fresh red blood (often streaking vomit)
- malaena rare
- often ceases spontaneously
= usually Hx of antecedent GORD-type symptoms
OESOPHAGEAL CANCER
- usually small amounts of blood (except pre-terminal when more)
- may be recurrent until malignancy managed
= dysphagia, systemic symptoms such as weight loss
MALLORY-WEISS TEAR
- typically brisk small-moderate volume of bright red blood
- malaena rare
- usually ceases spontaneously
= Hx of repeated vomiting (treat cause of this! eg anti-emetics for morning sickness)
VARICES
- usually large volume fresh blood
- swallowed blood can -> malaena
- often associated with haemodynamic instability
- may stop spontaneously, but re-bleeds common until appropriately managed
= Hx of alcohol abuse or other liver disease
TYPICAL PRESENTATION of causes of GASTRIC BLEED:
- gastric cancer?
- dieulafoy lesion?
- diffuse erosive gastritis?
- gastric ulcer?
(incl amount + appearance of blood AND associated symptoms + other features of history)
also if tend to stop spontaneously or not
GASTRIC CANCER
- may be frank haematemesis or altered blood mixed with vomit
- amount of bleeding variable (erosion of major vessels may -> large haemorrhage)
= prodromal dyspepsia + systemic Ca symptoms
DIEULAFOY LESION
- may produce quite considerable bleeding
- may be difficult to detect endoscopically
= often no prodromal features prior to haematemesis + malaena
DIFFUSE EROSIVE GASTRITIS
- usually haematemesis (coffee ground or fresh) and epigastric discomfort
- large haemorrhage may occur with haemodynamic instability
= Hx of underlying cause: eg recent NSAID etc use, often have epigastric discomfort
GASTRIC ULCER
- small low volume bleeds more common -> iron-deficiency anaemia
- erosion into a significant vessel may -> significant haematemesis
= tend to present with symptoms (and RFs) of PUD and iron-deficiency anaemia
What is a DIEULAFOY LESION?
about 1% of all GI bleeds
condition characterized by a large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes and bleeds.
it is an arteriovenous malformation
It can present in any part of the gastrointestinal tract
can be hard to detect on OGD
