A3- Lower + Upper GI Bleeding Flashcards
WHat is GI Bleeding
• Blood loss originating from any point of GI tract (mouth to anus).
What is lower GI bleed
• Blood loss originating from site distal to ligament of Treitz
What is upper GI bleed
• Blood loss originating from site proximal to ligament of Treitz.
What is Melaena?
• Black tarry faeces that are associated with UGI bleeding.
What is haematemesis
• Vomiting of blood
What is Haematochezia?
• Passage of maroon or bright red blood or blood clots per anus.
Ligament of Treitz
Defines the bend between the duodenum from the jejunum
WHat does occult lower GI bleeding mean
it is a classificaiton
patients usually present with anaemia
What do you ask about the blood
Colour: •Bright red • Dark red, maroon • Clots
Consistency: • Tarry, sticky • Jelly like • Fluid
Smell: • Fresh blood •Altered digested blood
What to ask in history of compliant? bleeding
When
How long/how often/how often
abdominal pain
associated symptoms
weight loss, red flag symptoms
PMHx
what to look out for in bleedign
IHD, angina
Diverticular disease
Haematological disorders
Surgical Hx
Recent travel
What medicaiton do we need to know about in relation to GI bleedign
Anticoagulants
iron tablets
NSAIDs
What to look out for in social hx?
alcohol
smoking
fitness assessment
WHat to look out for in skin, neurology and abdomen for patient with GI bleeding
Differential diagnosis
for GI bleedign
Management of ccult to moderate LGI bleed
Ensure patient is haemodynamically stable
History and examination (DRE and proctoscopy)
Biochemistry: Full blood count, iron studies, faecal calprotectin
Imaging: Flexible sigmoidoscopy, colonoscopy, CT colonography, CT abdomen, MRI abdomen
Referral to tertiary care – ? Capsule (VCE)
Management of massive LGI bleed
Main principles are
- resuscitate 2. stop the bleeding
WHat do score do you use to check if the patient is safe to be discharged after a lower GI bleed
Oakland Score
What components do you look at in th eoakland score?
What is the resuscitation principles for GI bleed
- Enlist help and escalate early.
- X2 large bore cannulae.
- Bloods for crossmatch.
- Fluid resuscitation with crystalloid first then think blood.
- Remember massive transfusion protocol.
- Monitor urine output.
- Reverse anticoagulation if possible
- TXA
what is the Massive transfusion Protocol?
Significance of colonoscopy?
- Can be diagnostic of all sources of bleeding.
- Efficient and cost effective.
- Can have therapeutic possibilities.
Cons:
- Less useful in major bleed.
- Good views require bowel prep.
- Invasive.
- Difficult to complete out of hours.
What is the Sensitivity and Specificity of CT angiography
Sensitivity 86%
Specificity 95%
Pros and Cons of Mesenteric angiography
- No bowel prep required. • Therapeutic possibilities with high accuracy and localisation.
- Requires active bleeding. • Less sensitive to venous bleeds (need prolonged exposure times). •Invasive therefore potential complications.
Pros and COns of Radionuclide Scintigraphy
- Label red blood cells detect the slowest bleeding rate 0.1- 0.5mL/min but cannot reliably localise site of bleeding. • Non invasive. • No bowel prep. • Repeatable investigation.
- Non therapeutic. • May delay intervention. • Diagnosis has to be confirmed by other means
Significance of capsule endoscopy?
- Can identify small bowel bleeding sites
- Role in active bleeding to be defined.
If surgery is done
known source is called
unknown source is called
- If known source –selective colectomy.
- If unknown source – on table endoscopy +/- subtotal colectomy
Common Upper GI bleeds?
In the “other/no obvious cause” category for upper GI bleed
examples?
- Angiodysplasia
- Gastric antral vascular ectasia (GAVE)
- Dieulafoy lesion
- Hereditary haemorrhagic telangiectasia (HHT)
- Portal hypertensive gastropathy
- Aorto-duodenal or Aorto-enteric fistula
What is the (Glasgow) Blatchford Score
Assessment tool to be done to aid decision for when endoscopy
should be performed
➢ Score of 0-2
What is the score called where you are Establishing severity, likelihood, and mortality
Rockall Score
How do you classify how much blood is lost?
Initial Management for upper GI bleed
•Airway
•Breathing
•Circulation
•Disability
•Exposure
(Don’t Ever Forget Glucose)
(Round you go again)
Blood-related investigations for suspected
UGI bleed
- FBC
- U/E
- LFTs
- INR/Coag
- Blood Gas + Glucose
- Group and Save Vs Crossmatch Vs Major haemorrhage protocol
Management of non-variceal bleed
As always these are your options
➢ (Non-pharmacological/pharmacological/conservative)
➢ Endoscopic
➢ Interventional Radiology: angiography and embolisation
➢ Surgical: resection
Endoscopic management of non-variceal bleed
Three main methods for achieving haemostasis
➢ Adrenaline + Mechanical: Clips
➢ Adrenaline + Thermal coagulation: heat probes, argon plasma
➢ Adrenaline + Fibrin or thrombin: Haemospray
Post-endoscopy intervention: Pharmacological treatment
1) Existing medication
• Education on NSAID use
• Decide risk vs benefit for anticoagulation, when to restart/ should we restart
2) Eradication
• H. pylori eradication
3) Hong Kong Regime for PPI
• 80mg Omeprazole stat + 8mg/hour over 72 hours
4) Rescope
What is the Child-Pugh Score
he Child-Pugh score is a system for assessing the prognosis — including the required strength of treatment and necessity of liver transplant — of chronic liver disease, primarily cirrhosis. It provides a forecast of the increasing severity of your liver disease and your expected survival rate.
Management of acute Variceal Bleed At presentation
➢ Fluid resus (blood vs saline vs gelofusin vs HAS)
➢ Terlipressin (2mg IV 4 hourly)
➢ Prophylactic antibiotic therapy (Broadspectrum)
At endoscopy
➢ Band ligation
➢ N-butyl-2-cyanoacrylate
Management post endoscopy (variceal)
- Fluid replacement – preferably 4.5% HAS
- Terlipressin: stop after definitive treatment has been achieved
- Pabrinex (I + II) 2 pairs TDS
- (Do not confuse with “Parvolex”)
- Laxatives (prevents encephalopathy)
- Re-scope to assess bands
- Varices surveillance
