Acute Gastrointestinal Bleeding Flashcards
Define upper GI bleeding.
Bleeding from oesophagus, stomach or duodenum
Proximal to ligament of Trietz
Define lower GI bleeding.
Bleeding distal to the duodenum.
Distal to ligament of Trietz.
What is the presentation for upper GI bleeding?
Haematemesis (vomiting fresh blood)
Melaena (black stool)
Elevated urea
Dyspepsia, reflux, epigastric pain
Which drug can cause upper GI bleeding?
NSAID
What is the presentation of lower GI bleeding?
Fresh bloods/clots in stool
Magenta stool
Normal urea
Usually painless
What are peptic ulcers caused by?
Imbalance of natural defences of stomach which can be worsened by the presence of additional factors like peptic enzymes which can digest proteins in the stomach lining.
How does the stomach usually protect itself from peptic enzymes?
Secretion of mucous which is alkaline which can neutralize the peptic acid.
List some factors which increases an individual’s risks of peptic ulceration.
H.pylori infection
Smoking
Alcohol
Medication
Ischaemia
Shock
What can peptic ulceration cause to happen?
Fibrosis and granulation tissue which can increase chances of gastric carcinoma/lymphoma.
Which type of peptic ulcers are more common- gastric or duodenal?
Duodenal
What are the risk factors for a duodenal ulcer?
H.pylori infection
NSAIDs/Aspirin
Also alcohol excess or stress ulcers
How do H.pylori bacteria cause ulceration?
-H.pylori penetrates mucous layer and adheres to epithelium.
-They produce urease which converts urea to ammonia.
-Ammonia acts as a buffer against gastric acid.
-Proliferation of H.pylori
-Ulcer production due to high acid secretion, loss of mucous, epithelial damage and inflammatory cell recruitment.
Name two common NSAIDs
~(NSAIDs a common cause of peptic ulceration).
Ibuprofen
Diclofenac
How do NSAIDs cause peptic ulceration?
Inhibit pathways, mainly COX-1, reducing mucous secretion leading to more damage
As gastric ulcers increase risk of gastric carcinoma, what should be done in those with gastric ulcers?
Repeat endoscopy after 8 weeks.
Ulcer may be sitting over a carcinoma.
Which syndrome causes poor healing of gastric ulcers?
Zollinger-Ellison syndrome- (gastrin secreting pancreatic tumour)
What are the causes of gastritis and duodenitis?
Tend to bleed to causes of impaired coagulation:
-Medical conditions
-Anti-coagulants
-Anti-platelets
RECAP- name some anti-coagulants
Warfarin
Rivaroxaban
Apixaban
RECAP- name some anti-platelets
Clopidogrel
Ticagrelor
What may cause bleeding of the oesophagus due to oesophagitis?
-Oesophageal reflux
-Alcohol
-Hiatus hernia
-Systemic illness
-Bisphosphates
What causes an enlarged spleen?
Portal hypertension
What causes varices?
Portal hypertension due o liver cirrhosis
What are varices?
Abnormally dilated collateral vessels
->usually a blockage type thing so blood cannot go through liver so has to find alterative paths causing vessels to swell and expand.
What is the typical presentation of oesophageal cancer?
Dysphagia/weight loss history
What can gastric cancer present as?
Gastric ulcer
What is a Mallory-Weiss tear?
Linear tear at oesophageal-gastric junction following a period or retching or vomiting
Diuelafoy is another cause of upper GI bleeding. Describe what it is.
Submucosal arterial vessel erodes through the mucosa, often into the gastric fundus.
Angiodysplasia is another cause of upper GI bleeding. Describe what it is.
Vascular malformations which can occur anywhere in the GI tract.
Can cause frequent occult or occult bleeding.
Which conditions are angiodysplasia commonly associated with?
Heart valve replacement
What may be a cause of lower GI bleeding if there is fresh blood passed upon straining but is painless?
Haemorrhoids
What are the more common causes of lower GI bleeding?
Haemorrhoids
Diverticular disease
What is diverticulosis?
(read carefully!)
Protrusion of the inner mucosal layer through the outer mucosal layer forming a pouch.
When does diverticulosis become diverticulosis?
When diverticulosis becomes inflamed.
What is the treatment for diverticular disease?
Usually self limiting as bleeding often stops spontaneously. However, once bleeding has occurred, there is a higher chance of it happening again.
What are haemorrhoids?
Enlarged vascular cushions around the anal canal
Describe what is experienced w haemorrhoids.
Usually painless but may be painful if thrombosed or external.
Bleeding upon defaecation.
Associated with constipation, low fibre diet and straining.
What is the treatment for haemorrhoids?
Elective surgical intervention.
Topical creams.
What is the treatment for angiodysplasia?
Argon Phototherapy
What is bleeding of angiodysplasia usually caused by?
Anti-coagulants
Anti-platelets
What are two forms of colonic neoplasma?
Colonic polyps
Colonic neoplasm
What is ischaemic colitis?
Disruption of blood flow to the colon
How does ischaemic colitis present?
Crampy abdominal pain, usually in those >60
What are some potential complications of ischaemic colitis?
Gangrene
Perforation
What is radiation proctitis?
Inflammation caused by radiotherapy
Which cancer’s is radiation proctitis usually associated with?
Prostate cancer
Cervical cancer
How does radiation proctitis usually present?
Crescendo PR bleeding, often occurs 1 or 2 years after radiotherapy
What is the treatment for radiation proctitis?
-APC- using ionised gas to clot blood/form scar tissue to prevent bleeding
-Sulcrafate enemas- forms protective layer to prevent bleeding
-Hyperbalic oxygen- 100% oxygen
List the causes of lower GI bleeding which originate in the small intestine.
Meckel’s diverticulum
Small bowel angiodysplasia
Small bowel tumour
Small bowel ulceration
Aortoentero fistula- following AAA repair
Which drug is associated with small bowel ulceration as a cause of lower GI bleeding?
NSAIDs
List some of the investigations used for the small bowel to identify causes of lower GI bleeding
CT angiogram using contrast
Meckel’s scan
Capsule endoscopy (swallowing a pill camera)
Double balloon enteroscopy
What is Meckel’s diverticulum?
Gastric reminant mucosa
Where would you see the Gastric reminant mucosa found in Meckel’s diverticulum?
2ft from ileocaecal valve, 2inches long
Why is Meckel’s diverticulum bad?
The gastric reminant mucosa may produce gastric acid which can cause ulcers
What is meant by shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia.
How does the body react to shock?
High resp. rate
High heart rate
Anxiety or confusion
Pale, clammy skin
Low urine output
Low blood pressure
Name some of the scoring systems used to determine whether a patient is at risk of an upper GI bleed.
Rockall score
Glasgow Blatchford score
What would be worrying when assessing for shock in terms of a GI bleed?
High urea
Low haemoglobin
There is no validated scoring system for assessing risk of a lower GI bleed. However, what are some of the symptoms which could suggest one?
Advanced age
Co-morbidity- if a patient has 2 or more conditions
Inpatients
Initial shock
Drugs- like NSAIDs and Aspirin
If the bleeding comes from the upper GI, which investigation is used to make a specific diagnosis?
Endoscopy
If the bleeding comes from the lower GI, which investigation is used to make a specific diagnosis?
Colonoscopy or CT angiogram (especially CT if patient has ongoing bleeding)
->think, if it’s lower, putting a camera down the throat isn’t going to be effective as it’s going to have a long way to travel before getting to the issue.
If a patient has a GI bleed, it is important to stop any medications that might be contributing to this.
It may be useful to use things to reverse certain medications. What could be used to reveres the affects of warfarin, a commonly used anticoagulant?
Vitamin K
Beriplex
If stopping certain drugs, what is important to remeber?
To start them again when the patient is stable., after about five days, or they could die from other conditions like MI.
Which specific medications may reduce the bleeding?
PPIs
Tranexamic acid
~(can increase thrombosis risk so have to be careful)
What is the first stage of management for patients with a GI bleed, before calculating their risk score?
Resuscitate them and get them stable
What can endoscopes allow as well as identifying the condition?
Can be used to direct medicine directly down the tube to the issue.
What are some of the endoscopic therapy options to reduce bleeding?
Injection of adrenaline
Thermal contact w/gold probe
Mechanical clip
What is the most effective combination of endoscopic therapy to stop bleeding?
Injection of adrenaline + thermal gold probe or clips.
Why are PPI’s useful in those with ulcers?
Proton pump pumps out positive H ions which increase acid secretion and cause an ulcer, so inhibiting this pump reduces acid.
What should be done if the ulcer bleeding is ongoing and cannot be treated endoscopically?
Angiography with embolization (finding source of bleeding and then embolising it).
Laparotomy
What is the management for varices?
Endoscopy with endotherapy
Where do varices most often occur?
Oesophagus
What works well for the vast majority of oesophageal varices?
Band ligation
If endoscopic treatment for varices isn’t sufficient, what may be carried out alongside the procedure?
-Terilpressen (drug)
-Antibiotics
-Reverse abnormal coagulation
Which blood supply does terlipressen vasoconstrict?
Splanchnic blood supply
What are the treatment options for varices if bleeding is ongoing and uncontrollable endoscopically?
Senstaken-Blakemore tube (tube that goes through nose or mouth to the stomach and has a balloon at the bottom)
TIPSS
Discuss what happens in TIPSS
Entry into systemic blood supply via the transjugular vein without going through a very scarred liver
