Acute Gastrointestinal Bleeding Flashcards
What is the incidence of GI bleed in the UK?
180/100000
What is the overall mortality of acute GI bleed?
10%
What mainly affects the outcomes of GI bleed?
Identification and promp management
Where can upper GI bleeding occur from?
Oesophagus
Stomach
Duodenum
anywhere proximal to ligament of Trietz
Where can lower GI bleeding occur from?
Bleeding distal to duodenum (jejunum, ileum, colon)
Distal to ligament of Trietz
What is the clinical presentation of upper GI bleed?
Haematemesis
Melaena
Elevated urea (digested blood turns haem into urea)
Dyspepsia, reflux, epigastric pain
What is the clinical presentation of lower GI bleeding?
Fresh blood/clots
Magenta stools
Normal urea (rarely elevated if proximal small bowel origin)
Typically painless
What can cause upper GI bleeds in the oesophagus?
Oesophageal ulcer
Oesophagitis
Oesophageal varices
Mallory Weiss Tear
Oesophageal malignancy
What can cause upper GI bleeds in the stomach?
Gastric ulcer
Gastritis
Gastric varices
Portal hypertensive gastropathy
Gastric malignancy
Dieulafoy
Angiodysplasia
Are duodenal ulcers or gastric ulcers more common?
Duodenal ulcers (75%)
What are risk factors for peptic ulcers?
Helicobacter pylori
NSAIDs/aspirin
Alcohol excess
Systemic illness (stress ulcers)
How does helicobacter pylori lead to gastric ulcers?
Produces urease -> amonia produced -> buffers gastric acid locally -> increased acid production
How does NSAIDs lead to gastric ulcers?
Prostaglandin production -> reduces mucus and bicarbonate excretion -> reduces physical defences
Why when a gastric ulcer is present is a repeat endoscopy indicated at 8 weeks?
They may have been sitting over a gastric carcinoma
What is Zollinger-Ellison syndrome also known as?
Gastrin-secreting pancreatic tumour
How does Zollinger-Ellison syndrome impact duodenal ulcers?
Causes poor healing of duodenal ulcers
What are the risk factors for gastritis and duodenitis similar to?
Risk factors for gastric and duodenal ulcer
What tends to cause gastritis and duodenitis to bleed?
Medical conditions
Anti-coagulants
Anti-platelets
What are examples of anti-coagulants?
Warfarin
Rivaroxaban
Apixaban
Dabigatran
LMWH
What are examples of anti-platelets?
Clipidogrel
Ticagrelor
What are risk factors for oesophagitis?
Reflux oesophagitis
Hiatus hernia
Alcohol
Biphosphonates
Systemic illness
When is oesophagitis most likely to have significant bleeding?
When on anti-platelets or anti-coagulatns
What are varices secondary to?
Portal hypertension, usually due to liver cirrhosis
What are varices?
Abnormally dilated collateral vessels
What are different types of varices?
Oesophageal (90%)
Gastric (8%)
Rectal and splenic (rare)
What are examples of upper GI malignancies?
Oesophageal cancer
Gastric cancer
What is a Mallory-Weiss tear?
Linear tear at oesophageal-gastric junction
What does a Mallory-Weiss tear follow a period of?
Vomiting and retching
What is Diuelafoy?
Submucosal arteriolar vessel eroding through mucosa
Where does Diuelafoy commonly occur?
Gastric fundus
What is an angiodysplasia?
Vascular malformation
Where can an angiodysplasia occur?
Anywhere along the GI tract
What chronic conditions is angiodysplasia associated with?
Heart valve replacement
What investigation is done for upper GI bleeding?
Upper endoscopy
When should an endoscopy be done for an upper GI bleed?
Within 24 hours, sooner if unstable
What are some colonic causes of lower GI bleeding?
Diverticular disease
Haemorrhoids
Vascular malformation (angiodysplasia)
Neoplasia (carcinoma or polyps)
Ischaemic colitis
Radiation enteropathy/proctitis
IBD (such as ulcerative colitis or Crohn’s disease)
What does diagnosis of a lower GI bleed require?
Flexible sigmoidoscopy or full colonoscopy
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
What does diverticulosis mean?
Presence
What does diverticulitis mean?
Inflammation
What is the main risk of diverticular disease?
Further bleeding (10% chance of reccurent at one year, 25% at four years)
What are haemorrhoids?
Enlarged vascular cushions around anal canal
When are haemorrhoids painful?
If thrombosed or external
What are haemorrhoids associated with?
Straining/constipation/low fibre diet
What is the treatment for haemorrhoids?
Elective surgical intervention
What is bleeding due to angiodysplasia often precipitated by?
Anticoagulants/antiplatelets
What is the treatment for angiodysplasia?
Argon phototherapy
Medication including tranexamic acid, thalidomide
What are different kinds of colonic neoplasia?
Colonic polyps or carcinoma
What is ischaemic colitis?
Disruption in blood supply to the colon
What determines what area of the colon ischaemic colitis affects?
Which blood vessels are affected
What does ischaemic colitis typically affect?
Descending/sigmoid colon
What are possible complications of ischaemic colitis?
Gangrene
Perforation
What is usually present in radiation proctitis?
Previous history of radiotherapy (cerival cancer, prostate cancer)
What is the treatment for radiation proctitis?
APC
Sulcrafate enemas
Hyperbaric oxygen
What does treatment of IBD depend on?
Extent/severity
What investigations are done for acute lower GI bleeding?
Flexible sigmoidoscopy
Colonoscopy
CT angiogram
When should small bowel origin of bleeding be considered?
If no colonic cause is found and upper GI bleeding is excluded
What percentage of GI bleeds are small bowel?
5%
What are small bowel causes of lower GI bleeding?
Meckel’s diverticulum
Small bowel angiodysplasia
Small bowel tumour
Small bowel ulceration (NSAID associated)
Aortoentero fistulation
What investigations can be done to look at bleeding in the small bowel?
CT angiogram
Meckel’s scan (Scintigraphy)
Capsule endoscopy
Double balloon enteroscopy
What is Meckel’s diverticulum?
Gastric reminant mucosa 2 feet from ileocaecal valve that is 2 inches long
What is used to diagnose Meckel’s diverticulum?
Nuclear scintgraphy
What is gastrointestinal bleeding managed by?
ABCDE
airway
breathing
circulation
disability
exposure
What management in terms of circulation is done for gastrointestinal bleeding?
Wide broad IV access to give IV fluids, blood transfusions
Urgen blood samples to lab (FBC, U&Es, LFT, coagulation, blood group)
Blood transfusions if Hb<7g/dL or ongoing active bleeding
When is a blood transfusion given for gastrointestinal bleeding?
If Hb<7g/dL
What does the management of GI bleeding involve?
ABCDE
Endoscopy once stable
Withhold/reverse contributory medication if able to
Blood products if ongoing bleeding
Specific medications
Consider CT angiography/interventional radiology/surgical intervention as appropriate
When is an IV for GI bleeding given?
If platelets < 50
When is fresh frozen plasma (FFP) given for GI bleeding?
If INR or APTT > 1.5x normal range or Cryoprecipitate if fibrinogen <1.5g/L
What is shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
What is the clinical presentation of shock?
Tachypnoea
Tachycardia
Anxietry or confusion
Cool clammy skin
Loguria
Hypotension
What are the different stages of shock?
Stage 1
Stage 2
Stage 3
Stage 4
What things does shock classification consider?
Volume lost
% blood lost
Respiratory rate
Heart rate
Blood pressure
Pulse pressure
Consciousness level
What is considered to be stage 1 shock?
What is considered to be stage 2 shock?
What is considered to be stage 3 shock?
What is considered to be stage 4 shock?
What is used for risk stratification for upper GI bleeding?
Rockall score
Other than Rockall score, what else can be used to risk stratification of upper GI bleeding?
Blatchford score
What are the different stages of the rockall score?
0
1
2
3
What does the rockall score consider?
Age
Shock
Co-morbidity
Diagnosis
Major stigmata of recent haemorrhage
What is considered 0 for the rockall score?
What is considered 1 for rockall score?
What is considered 2 for the rockall?
What is considered 3 for the rochall score?
What things are considered for the blatchford score?
Blood urea (mmol/L)
Haemoglobin (g/L)
Systolic blood pressure
Pulse
Hepatic disease
Cardiac failure
What is low risk criteria for Glasgow blatchford score?
Urea < 6.5mmol/L
Haemoglobin >= 130g/L (men) or >= 120g/L (women)
Systolic blood pressure >= 110mmHg
Pulse < 100bpm
Absence of melaena, syncope, cardiac failure or liver disease
What score for the blatchford score is associated with greater than 50% risk of needing an intervention?
>=6
What scoring system is used for risk stratification of lower GI bleeding?
There is no validated scoring system
Is the relationship between age and mortality more defined in lower or upper GI bleeding?
Acute lower GI bleeding occurs most often in the elderly
Age and mortality association more associated with lower GI bleeding
What is the relationship between co-morbidity and severe bleed?
Presence of two co-morbidities doubles the change of a severe bleed
How does inpatients who have rectal bleeding impact mortality?
Inpatients with rectal bleeding have 23% mortality compared with 3.6%
How do drugs impact the risk of lower GI bleeding?
Patients taking aspirin and NSAIDS are at increased risk
OR 1.8-2.7
What is the benefit of using dedicated teams to manage acute GI bleeding?
Improved mortality
Why does having dedicated teams improve the outcome of acute GI bleeding?
Protocolised care
Prompt resuscitation
Close medical and surgical liaison
What is the management of a peptic ulcer?
Proton pump inhibitor
Endoscopy with endotherapy
If bleeding is uncontrollable, then laparotomy
What are endoscopic therapy to pathology options for the management of a peptic ulcer?
Injection (adrenaline)
Thermal
Mechanical (clip)
Haemospray
Combination therapy is the most effective
What is the management for a peptic ulcer when bleeding is uncontrollable?
Angiography with embolisation
Laparotomy
What is the management of varices?
Endotherapy
Intubated for airway protection
IV Terlipressin
IV broad spectrum antibiotics
Correct coagulopathy
What are different kinds of endotherapy for oesophageal varices?
Band ligation
Glue injection
What are different kinds of endotherapy for gastric varices?
Glue injection
What are different kinds of endotherapy for rectal varices?
Glue injection
What is Terlipressin?
Vasoconstrictor of splanchnic blood supply, reducing portal pressures by reducing blood flow
