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Acute Gastrointestinal Bleeding Flashcards

1
Q

What is the incidence of GI bleed in the UK?

A

180/100000

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2
Q

What is the overall mortality of acute GI bleed?

A

10%

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3
Q

What mainly affects the outcomes of GI bleed?

A

Identification and promp management

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4
Q

Where can upper GI bleeding occur from?

A

Oesophagus

Stomach

Duodenum

anywhere proximal to ligament of Trietz

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5
Q

Where can lower GI bleeding occur from?

A

Bleeding distal to duodenum (jejunum, ileum, colon)

Distal to ligament of Trietz

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6
Q

What is the clinical presentation of upper GI bleed?

A

Haematemesis

Melaena

Elevated urea (digested blood turns haem into urea)

Dyspepsia, reflux, epigastric pain

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7
Q

What is the clinical presentation of lower GI bleeding?

A

Fresh blood/clots

Magenta stools

Normal urea (rarely elevated if proximal small bowel origin)

Typically painless

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8
Q

What can cause upper GI bleeds in the oesophagus?

A

Oesophageal ulcer

Oesophagitis

Oesophageal varices

Mallory Weiss Tear

Oesophageal malignancy

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9
Q

What can cause upper GI bleeds in the stomach?

A

Gastric ulcer

Gastritis

Gastric varices

Portal hypertensive gastropathy

Gastric malignancy

Dieulafoy

Angiodysplasia

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10
Q

Are duodenal ulcers or gastric ulcers more common?

A

Duodenal ulcers (75%)

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11
Q

What are risk factors for peptic ulcers?

A

Helicobacter pylori

NSAIDs/aspirin

Alcohol excess

Systemic illness (stress ulcers)

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12
Q

How does helicobacter pylori lead to gastric ulcers?

A

Produces urease -> amonia produced -> buffers gastric acid locally -> increased acid production

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13
Q

How does NSAIDs lead to gastric ulcers?

A

Prostaglandin production -> reduces mucus and bicarbonate excretion -> reduces physical defences

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14
Q

Why when a gastric ulcer is present is a repeat endoscopy indicated at 8 weeks?

A

They may have been sitting over a gastric carcinoma

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15
Q

What is Zollinger-Ellison syndrome also known as?

A

Gastrin-secreting pancreatic tumour

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16
Q

How does Zollinger-Ellison syndrome impact duodenal ulcers?

A

Causes poor healing of duodenal ulcers

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17
Q

What are the risk factors for gastritis and duodenitis similar to?

A

Risk factors for gastric and duodenal ulcer

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18
Q

What tends to cause gastritis and duodenitis to bleed?

A

Medical conditions

Anti-coagulants

Anti-platelets

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19
Q

What are examples of anti-coagulants?

A

Warfarin

Rivaroxaban

Apixaban

Dabigatran

LMWH

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20
Q

What are examples of anti-platelets?

A

Clipidogrel

Ticagrelor

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21
Q

What are risk factors for oesophagitis?

A

Reflux oesophagitis

Hiatus hernia

Alcohol

Biphosphonates

Systemic illness

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22
Q

When is oesophagitis most likely to have significant bleeding?

A

When on anti-platelets or anti-coagulatns

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23
Q

What are varices secondary to?

A

Portal hypertension, usually due to liver cirrhosis

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24
Q

What are varices?

A

Abnormally dilated collateral vessels

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25
What are different types of varices?
Oesophageal (90%) Gastric (8%) Rectal and splenic (rare)
26
What are examples of upper GI malignancies?
Oesophageal cancer Gastric cancer
27
What is a Mallory-Weiss tear?
Linear tear at oesophageal-gastric junction
28
What does a Mallory-Weiss tear follow a period of?
Vomiting and retching
29
What is Diuelafoy?
Submucosal arteriolar vessel eroding through mucosa
30
Where does Diuelafoy commonly occur?
Gastric fundus
31
What is an angiodysplasia?
Vascular malformation
32
Where can an angiodysplasia occur?
Anywhere along the GI tract
33
What chronic conditions is angiodysplasia associated with?
Heart valve replacement
34
What investigation is done for upper GI bleeding?
Upper endoscopy
35
When should an endoscopy be done for an upper GI bleed?
Within 24 hours, sooner if unstable
36
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)
37
What does diagnosis of a lower GI bleed require?
Flexible sigmoidoscopy or full colonoscopy
38
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
39
What does diverticulosis mean?
Presence
40
What does diverticulitis mean?
Inflammation
41
What is the main risk of diverticular disease?
Further bleeding (10% chance of reccurent at one year, 25% at four years)
42
What are haemorrhoids?
Enlarged vascular cushions around anal canal
43
When are haemorrhoids painful?
If thrombosed or external
44
What are haemorrhoids associated with?
Straining/constipation/low fibre diet
45
What is the treatment for haemorrhoids?
Elective surgical intervention
46
What is bleeding due to angiodysplasia often precipitated by?
Anticoagulants/antiplatelets
47
What is the treatment for angiodysplasia?
Argon phototherapy Medication including tranexamic acid, thalidomide
48
What are different kinds of colonic neoplasia?
Colonic polyps or carcinoma
49
What is ischaemic colitis?
Disruption in blood supply to the colon
50
What determines what area of the colon ischaemic colitis affects?
Which blood vessels are affected
51
What does ischaemic colitis typically affect?
Descending/sigmoid colon
52
What are possible complications of ischaemic colitis?
Gangrene Perforation
53
What is usually present in radiation proctitis?
Previous history of radiotherapy (cerival cancer, prostate cancer)
54
What is the treatment for radiation proctitis?
APC Sulcrafate enemas Hyperbaric oxygen
55
What does treatment of IBD depend on?
Extent/severity
56
What investigations are done for acute lower GI bleeding?
Flexible sigmoidoscopy Colonoscopy CT angiogram
57
When should small bowel origin of bleeding be considered?
If no colonic cause is found and upper GI bleeding is excluded
58
What percentage of GI bleeds are small bowel?
5%
59
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
60
What investigations can be done to look at bleeding in the small bowel?
CT angiogram Meckel's scan (Scintigraphy) Capsule endoscopy Double balloon enteroscopy
61
What is Meckel's diverticulum?
Gastric reminant mucosa 2 feet from ileocaecal valve that is 2 inches long
62
What is used to diagnose Meckel's diverticulum?
Nuclear scintgraphy
63
What is gastrointestinal bleeding managed by?
ABCDE airway breathing circulation disability exposure
64
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
65
When is a blood transfusion given for gastrointestinal bleeding?
If Hb\<7g/dL
66
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
67
When is an IV for GI bleeding given?
If platelets \< 50
68
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
69
What is shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
70
What is the clinical presentation of shock?
Tachypnoea Tachycardia Anxietry or confusion Cool clammy skin Loguria Hypotension
71
What are the different stages of shock?
Stage 1 Stage 2 Stage 3 Stage 4
72
What things does shock classification consider?
Volume lost % blood lost Respiratory rate Heart rate Blood pressure Pulse pressure Consciousness level
73
What is considered to be stage 1 shock?
74
What is considered to be stage 2 shock?
75
What is considered to be stage 3 shock?
76
What is considered to be stage 4 shock?
77
What is used for risk stratification for upper GI bleeding?
Rockall score
78
Other than Rockall score, what else can be used to risk stratification of upper GI bleeding?
Blatchford score
79
What are the different stages of the rockall score?
0 1 2 3
80
What does the rockall score consider?
Age Shock Co-morbidity Diagnosis Major stigmata of recent haemorrhage
81
What is considered 0 for the rockall score?
82
What is considered 1 for rockall score?
83
What is considered 2 for the rockall?
84
What is considered 3 for the rochall score?
85
What things are considered for the blatchford score?
Blood urea (mmol/L) Haemoglobin (g/L) Systolic blood pressure Pulse Hepatic disease Cardiac failure
86
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
87
What score for the blatchford score is associated with greater than 50% risk of needing an intervention?
\>=6
88
What scoring system is used for risk stratification of lower GI bleeding?
There is no validated scoring system
89
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
90
What is the relationship between co-morbidity and severe bleed?
Presence of two co-morbidities doubles the change of a severe bleed
91
How does inpatients who have rectal bleeding impact mortality?
Inpatients with rectal bleeding have 23% mortality compared with 3.6%
92
How do drugs impact the risk of lower GI bleeding?
Patients taking aspirin and NSAIDS are at increased risk OR 1.8-2.7
93
What is the benefit of using dedicated teams to manage acute GI bleeding?
Improved mortality
94
Why does having dedicated teams improve the outcome of acute GI bleeding?
Protocolised care Prompt resuscitation Close medical and surgical liaison
95
What is the management of a peptic ulcer?
Proton pump inhibitor Endoscopy with endotherapy If bleeding is uncontrollable, then laparotomy
96
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
97
What is the management for a peptic ulcer when bleeding is uncontrollable?
Angiography with embolisation Laparotomy
98
What is the management of varices?
Endotherapy Intubated for airway protection IV Terlipressin IV broad spectrum antibiotics Correct coagulopathy
99
What are different kinds of endotherapy for oesophageal varices?
Band ligation Glue injection
100
What are different kinds of endotherapy for gastric varices?
Glue injection
101
What are different kinds of endotherapy for rectal varices?
Glue injection
102
What is Terlipressin?
Vasoconstrictor of splanchnic blood supply, reducing portal pressures by reducing blood flow

2A - Alimentary System (41 decks)

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