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systems- GI > Acute Gastrointestinal Bleeding > Flashcards

Acute Gastrointestinal Bleeding Flashcards

1
Q

state the common causes of acute gastrointestinal haemorrhage?

A

upper GI

lower GI

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2
Q

describe the principles of investigation and treatmentt of acute gastrointestinal haemorrhage

A

Any haemorrhage
Scoring systems
Specialist bleeding units
Specific situations

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3
Q

definition of upper GI bleeding

A

Bleeding from oesophagus, stomach or duodenum
Proximal to ligament of Trietz

Haematemesis
  Melaena
  Elevated Urea
Digested blood: haem -> urea 
 Associated with dyspepsia, reflux, epigastric pain
 Non-steroidal anti-inflammatory use
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4
Q

definition of lower GI bleeding

A

Bleeding distal to duodenum (jejunum, ileum, colon)
Distal to ligament of Trietz

Fresh blood/clots
Magenta stools
Normal urea (rarely elevated if proximal small bowel origin)
Typically painless 
More common in advanced age
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5
Q

causes of upper GI bleeding

A

ulcers of oesophagus, stomach and duodenum

-itis

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6
Q

are gastric ulcers more common than duodenal ulcers?

A

no

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7
Q

risk factors for peptic ulcers

A

Helicobacter pylori
produces urease -> ammonia produced
-> buffers gastric acid locally => increased acid production
NSAIDs/Aspirin
prostaglandin production -> reduced mucus and bicarbonate excretion => reduced physical defences

Alcohol excess
Systemic illness – “Stress ulcers”

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8
Q

what causes recurrent poor healing duodenal ulcers

A

zollinger-ellison syndrome

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9
Q

risk factors for gastritis and duodenitis?

A

Tend to bleed in context of impaired coagulation
Medical conditions
Anti-coagulants (warfarin, rivaroxaban, apixaban, dabigatran, LMWH)
Anti-platelets (clopidogrel, ticagrelor)

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10
Q

causes of oesophagi’s

A 
Reflux oesophagitis
Hiatus hernia
Alcohol
Bisphosphonates
Systemic illness
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11
Q

causes of varices

A 
Secondary to portal hypertension, usually due to liver cirrhosis
Abnormally dilated collateral vessels
Oesophageal (90%)
Gastric (8%)
Rectal and splenic (rare)

Increases in portal pressure (eg infection/drug use/alcohol use) can precipitate bleeding

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12
Q

causes of malignancy

A

Oesophageal cancer
May have dysphagia /weight loss history
Typically “ooze”

Gastric cancer
Can present as an ulcer
GU needs interval endoscopy for healing

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13
Q

what is mallory-weiss tear?

A

Linear tear at oesophago-gastric junction
Follows period of retching/vomiting
Up to 10% significant requiring endoscopic treatment

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14
Q

what is diuelafov?

A

Submucosal arteriolar vessel eroding through mucosa

Gastric fundus

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15
Q

what is Angiodysplasia

A

Vascular malformation
Occurs anywhere in GI tract
Frequent cause of chronic occult or overt occult bleeding
Associated with chronic conditions including heart valve replacement

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16
Q

investigations for upper GI bleeding

A

Upper GI Endoscopy:
Both diagnostic and therapeutic
Within 24 hours – sooner if unstable (NICE 2012)

17
Q

colonic causes of acute lower GI bleeding

A 
Diverticular disease
Haemorrhoids
Vascular malformations (angiodysplasia)
Neoplasia (carcinoma or polyps)
Ischaemic colitis
Radiation enteropathy/proctitis 
Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)

Diagnosis requires flexible sigmoidoscopy or full colonoscopy

18
Q

diverticular disease

A

Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch.

Diverticulosis - presence

Diverticulitis - inflammation

Bleeding occurs in 10-20% during the lifetime
Usually self-limiting - 75%

Risk of further bleeding
10% chance of recurrence at one year
25% at four years

19
Q

haemorrhoids

A

Enlarged vascular cushions around anal canal
Painful if thrombosed or external
Association with straining/constipation/low fibre diet
Common, rarely serious bleeding

Treatment is elective surgical intervention

20
Q

Acute lower GI haemorrhage: angiodysplasia

A

Vascular malformation
Degeneration
Friable and bleeds easily
May be association with heart valve abnormalities
Bleeding often precipitated by anticoagulants/antiplatelets
May be multiple including small bowel

Treatment with Argon Phototherapy, medication incl tranexamic acid, thalidomide

21
Q

ischaemic colitis

A

Disruption in blood supply to colon
Affects areas according to blood supply, typically descending/sigmoid colon
Presents with crampy abdominal pain and sudden bleeding

22
Q

whos more likely to get ischaemic colitis?

A

over 60

23
Q

complications of ischaemic colitis?

A

gangrene and perforation

24
Q

radiation proctitis

A 
Previous history of radiotherapy
Cervical cancer
Prostate cancer
Crescendo PR bleeding over months/years
May be dependent on blood transfusions due to chronic loss
25
Q

treatment of radiation proctitis

A

APC
Sulcrafate enemas
Hyperbaric oxygen

26
Q

investigations of acute lower GI bleeding

A

Lower GI endoscopy:
Flexible sigmoidoscopy – if large volume views limited
Colonoscopy – requires preparation

CT Angiography

27
Q

small bowel cause of acute lower bleeding?

A

If no colonic cause is found and upper GI bleeding excluded need to consider small bowel origin (5%)

Meckel’s diverticulum
Small bowel angiodysplasia
Small bowel tumour/GIST
Small bowel ulceration (NSAID associated)
Aortoentero fistulation – following AAA repair

28
Q

small bowel investigations

A

CT angiogram
Meckel’s scan (Scintigraphy)
Capsule endoscopy
Double balloon enteroscopy

29
Q

management of GI bleeding

A

A. Airway
B. Breathing
C. Circulation:
Wide bored IV access => IV fluids, blood transfusion
Urgent blood samples to lab: FBC, U&Es, LFTs, Coagulation, blood group and save/ cross match
Blood transfusion if Hb<7g/dl or ongoing active bleeding
Consider major haemorrhage protocol
Evidence that transfusing Hb>10g/dl has worse outcomes
Catheter
?? Tranexamic acid
D. Disability
E. Exposure

30
Q

risk stratification UGIB: blatchford score

pre-endoscopy score

A 
Blood urea (mmol/L) 
 Haemoglobin for men (g/L) 
 Haemoglobin for women (g/L) 
 Systolic blood pressure (mm Hg) 
 Other markers 
 Hepatic disease
 Cardiac failure
31
Q

risk stratification UGIB: Low-risk criteria of Glasgow Blatchford Score

A

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 associated with a greater than 50% risk of needing an intervention

32
Q

management of GI bleeding: peptic ulcer

A

Proton pump inhibitors

Endoscopy with endotherapy

Angiography with embolization

Laparotomy

33
Q

endosxopic therapy options for peptic ulcer

A 
Injection 
Adrenaline 1:10000
Thermal 
Contact – “gold probe”
Mechanical 
Clip
Haemospray
34
Q

management of varies

A

Endotherapy
Oesophageal
Band ligation
Glue injection

Gastric
Glue injection

Rectal
glue injection

IV Terlipressin
Vasoconstrictor of splanchnic blood supply
Reduces blood flow to portal vein, reducing portal pressures
Mortality reduced 32% to 12%

IV Broad spectrum antibiotics
Often precipitated by systemic infection

Correct coagulopathy

systems- GI (40 decks)

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