acute gastrointestinal bleeding Flashcards
Define upper GI bleeding
Bleeding from the oesophagus, stomach or duodenum - proximal to the ampulla of vater
Lower GI bleeding
Bleeding distal to the duodenum - jejunum, ileum and colon
Describe haematemesis
Vomiting of blood
Describe malaena
Blood in stool - darker if it is an upper GI bleed and more purple and brighter in lower GI bleed
What is upper GI bleed associated with
dyspepsia
reflux
epigastric pain
Painless
What is the urea levels in upper and lower GI bleeds
Upper GI - raised urea - partially digested blood broken down to haem which is then excreted as urea
Lower GI - normal urea
What are the causes of upper GI bleeds
Oesophageal ulcer
oesophagitis
Gastric ulcer
Gastritis
Duodenal ulcer
Duodenitis
What is the most common cause of an acute upper GI bleed
Duodenal ulcer
How does a peptic ulcer occur
The protective mucus layer becomes damages and then the acid in the area begins to damage the underlying layer which causes ulceration
What are the risk factors for peptic ulcer
H pylori
NSAIDS
aspirin
Describe how H pylori causes a peptic ulcer
H. pyloripenetrate the mucus layer of host stomach and adhere the surface of gastric mucosal epithelial cells.
produce ammonia from urea by the urease, and the ammonia netralize the gastric acid to escape from elimination.
prolifirate, migrate, and finally form the infectious focus.
The gastric ulcerization is developed by destruction of mucosa, inflammation and mucosal cell death.
How do NSAIDs cause peptic ulcers
They reduce the inflammatory responsw which reduces mucus production
What is Zollinger-Ellison syndrome
Gastrin-secreting pancreatic tumour which causes recurrent poor healing duodenal ulcers
What increases risk of upper GI bleeding
GORD - can lead to Barret’s oesophagus
Hiatus hernia
Alcohol
Bisphosphonates - bone protection meds which have oesophageal side effects
What are varices
Abnormally dilated collateral vessels, secondary to portal hypertension due to liver cirrhosis
What is a Mallory-Weiss tear
Linear tear at oesophago-gastric junction which follows period of vomiting
What is diuelafoy
Submucosal arteriolar vessel eroding through the mucosa
What are the colonic causes of lower GI bleeding
Diverticular disease
Haemorrhoids
vascular malformations
Neoplasia
ischaemic colitis
radiation proctitis
IBD
What is diverticular disease
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
What are haemorrhoids
Enlarged vascular cushions around the anal canal that are associated with constipation and a low fibre diet
Can present with itchiness and blood on wiping
What is ischaemic colitis and how does it present
Disruption in the blood supply to the colon which presents with crampy abdominal pain
What is shock
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypo-perfusion and tissue hypoxia
What is the presentation of shock
Tachycardia
Tachypnoea
anxiety or confusion
cool clammy skin
oliguria
hypotension
Describe the low-risk criteria of glasgow blatchford score
urea <6·5 mmol/L
haemoglobin >=130 g/L (men) or >=120 g/L (women)
systolic blood pressure >=110 mm Hg
pulse <100 beats per min
absence of melaena, syncope, cardiac failure, or liver disease
Scores 6 and over associated with >50% need of intervention
What are the endoscopic therapy options for a peptic ulcer
injection - adrenaline
Thermal - contact - gold prove
Mechanical - clip
Combination therapy of adrenaline + one of the other options is the most efficient
How do Proton pump inhibitors help the management of bleeding in a peptic ulcer
they reduce the acidity in the environment which promotes healing
What is the management of hepatic varices
endoscopy with endotherapy
e.g band ligation where the rubber band over the blood vessel causes it to necrose away
Terlipressin - vasoconstrictor which reduces blood flow to the portal vein
Antibiotics
Sengstaken-Blakemore tube
TIPSS
What is a sengstaken-Blakemore tube
Using ballooning which causes ballon tamponade - temporary measure which buys time to do TIPSS which is more permanent
What is TIPSS
Putting a shunt between the portal circulation and systemic circulation to bypass the liver
