Acute Gastrointestinal Bleeding Flashcards
What is upper GI bleeding?
Lower GI bleeding?
Bleeding from the oesophagus, stomach or duodenum
Lower: distal to duodenum (jejunum/ileum/colon)
What effect does upper GI bleeding have on stool colour?
Lower GI bleeding
Upper: malaena (dark sticky faeces, partially digested blood)
Lower: reddish stools
How does upper GI bleeding present?
Haematemesis
malaena
Elevated urea (from digestion of blood)
Dyspepsia/reflux/epigastric pain
How does lower GI bleeding present?
Bloody stools (reddish)
Normal urea
Typically painless
Causes of upper GI bleeding?
Ulcers (in oes, stomach, duod)
Inflammation (“itis of any of the structures)
Malignancy (oes. & gastric)
Angiodysplasia
Are duodenal or gastric ulcers more common?
Duodenal
Why does inflammation lead to upper GI bleeding?
Bleeds due to impaired coagulation ability
Worse if on anti-coagulant/anti platelet (LMWH, warfarin, clopidogrel)
Common cause of varices that lead to bleeding?
Portal hypertension - often liver cirrhosis
Where do most varices occur?
Oesophagus - 90%
Gastric - 8%
Rectal and splenic - rare
What is a Mallory-Weiss tear?
Tear in the lining at the oesophago-gastric junction, usually following retching/vomiting
Cause of upper GI bleeds
What is a Diuelafoy?
Erosion of submucosal artery through the mucosa (often localised in gastric fundus)
Cause of upper GI bleeds
What is angiodysplasia?
Malformation of vascular structures - can cause occult bleeding
Occurs anywhere in the GI tract
Colonic causes of acute lower GI bleeding?
Diverticular disease Vascular malformations Malignancy Ischaemic colitis Radiation enteropathy/proctitis IBD
What is diverticular disease?
Protrusion of the mucosal lining through the outer muscular layer
Can cause lower GI bleeds
What is a haemorrhoid?
Enlarged vascular cushions around the anal canal
Can cause lower GI bleeding - best treatment is surgical
What is ischaemic colitis?
Inflammation due to ischaemia in the bowel - presents with abdominal pain and sudden bleeding
What is radiation proctitis?
Inflammation of the rectum due to previous radiation exposure
Bleeding can occur for months/years - may begin to rely on blood transfusions
Causes of small bowel lower GI bleeding?
Meckel's diverticulum Angiodysplasia Malignancy Ulceration Aortoenteric fistula
Investigations for suspected small bowel bleeding?
CT angiogram
Meckel’s scan (scintigraphy)
Capsule endoscopy
Double balloon enteroscopy
What is Meckel’s diverticulum? Best investigation?
Congenital form of diverticular disease in the small bowel (at umbilical cord)
Nuclear Scintigraphy is diagnostic
Best management for GI bleeding?
DR ABCDE - for C may require blood transfusion & IV fluids
Endoscopy once stable - withold contributory medications (warfarin etc.)
Surgical/angiography interventions as needed
What is shock?
State of hypoperfusion to the tissues of the body due to circulatory collapse - can occur with GI bleeding
Signs of shock?
High resp rate High pulse rate Anxiety/confusion Cool, clammy skin Low urine output (oliguria) Low BP (hypotension)
What score is used to predict mortality after upper GI bleeding? What does it measure?
Rockall Score
- is there shock?
- Tachycardia?
- Hypotension?
- Co-morbidities/conditions?
What score is used to decide who needs endoscopy after upper GI bleeds? What does it measure?
Blatchford score
- Urea (mmol/L)
- Haemoglobin
- Systolic BP
- Markers for hepatic/cardiac/other disease
What is the scoring system for lower GI bleeding?
No validated scoring system
For risk stratification consider - age/co-morbidity/shock?/Drugs
Management of peptic ulcer derived GI bleeding?
PPI’s
H2 antagonists
Endoscopy
Treat underlying condition/stop bleeding by:
- injection (adrenaline - vasocontriction)
Management of varicies causing GI bleeds?
Band ligation/glue injection - both done endoscopically
IV Terlipressin - vasoconstrictor of splanchnic blood supply
If variceal bleeding is uncontrollable at endoscopy, what procedure is performed?
Transjugular intrahepatic porto-systemic shunt
