Acute Gastrointestinal Bleeding: Lower GI Bleeding Flashcards
What is the colonic cause of GI bleeding
Diverticular disease
Haemorrhoids
Vascular malformations (angiodysplasia)
Neoplasia (carcinoma or polyps)
Ischaemic colitis
Radiation enteropathy/proctitis
Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)
What is required for the diagnosis of Colonic Causes
Flexible simoidioscopy
Full colonoscopy
What is the pathology of Divericular disease
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
self limiting
increases risk of further bleeding
Define heamarroids
enlarged vascular cushions around the anal canal
- rarely cause serious bleeding
When does Haemorrhoids become painful
If thrombosed or external
What causes haemorrhoids
straining
Constipation
Low fibre diet
What is the treatment of haemorrhoids
Elective surgical intervention
How do you treat angiodysplasia
argon phototherapy
What are the two forms of colonic neoplasia that can cause acute lower GI bleed
Colonic polyps or carcinoma
What is the severity ofColonic polyps or carcinoma
very rare to cause life threatening bleeding
What is the pathology of ischaemic colitis
Disruption in blood supply to the colon - typically in the descending and sigmoid colon
What is the presentation of ischaemic colitis
- Crampy abdominal pain
- self limiting
What is the complications of ischaemic colitis
Gangrene
Perforation
What is the appearance of ischaemic colitis
Dusky blue
Swollen Mucosa
What is the aetiology of radiation proctitis (inflammation of rectum and anus)
Previous history of radiotherapy For:
Cervical cancer
Prostate cancer
What is the presentation of radiation proctitis
Crescendo bleeding through rectum
What is the treatment for radiation proctitis
Blood transfusion of chronic loss
APC
Sulcrafate enemas
Hyperbaric oxygen
What is the two forms of inflammatory bowel disease
Ulcerative colitis
Crohns disease
What is 5 small bowel causes that result in acute lower GI bleed
Meckel’s diverticulum
Small bowel angiodysplasia
Small bowel tumour/GIST
Small bowel ulceration (NSAID associated)
Aortoentero fistulation – following AAA repair
What is the investigations used for small bowel causes of lower GI bleed
CT angiogram
Meckel’s scan (Scintigraphy)
Capsule endoscopy
Double balloon enteroscopy
What is meckels diverticulum
2inches Budge in small intestine caused by an incomplete obliteration of the vitelline duct located 2 ft from ileocaecal
= gastric reminant mucosa
What is sued for the diagnosis of Mockers Diverticulum
Nuclear scintigraphy
What is the protocol for a major haemorrhage
ABCDE Approach
Blood transfusion
Endoscope once stable within 24 hours
Withhold contributory medication
(eg vitamin K if on warfarin)
Consider:
CT angiography
interventional radiology
surgical intervention
When does a blood transfusion occur in GI bleeding
Hb <7g/dl
On going active bleeding
What are the blood tests taken in major haemorrhage protocol
and what is inserted
FBC U&E LFT Coagulation Blood group
Catheter is inserted
When is required medicine re commended in GI bleeding
Once haemostasis is achieved
How does cirulcarory shock arise
inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
What is the symptoms of circulatory shock
Tachypnoea Tachycardia Anxiety/ confusion Cool clammy skin Oliguria Hypotenion
What does risk stratification consider to predict the likelihood of a re-bleeding occurring
Age
Shock
Co-morbidity
Diagnosis
Major stigmata of recent haemorrhage
What is considered to determine if endoscopic intervention is required
Blood urea
Haemoglobin
Systolic blood pressure
Heart rate
Other markers:
Hepatic disease
Cardiac failure
Score >6 means 50% risk of needing intervention
What does the risk stratification of Lower GI bleeding consider
Age - increased in elderly
Co-morbidity
Inpatients
Initial shock +gross rectal bleeding
Drugs - NSAIDS/aspirin
What is the management of peptic ulcers
Proton pump inhibitors - omeprazole
Endoscopy with endotherapy
Angiography with embolization
Laparotomy
What is the two benefits of endoscopic management of peptic ulcers
Identify those at high risk of further bleeding
Endoscopic therapy to pathology
What is the 4 forms of endoscopic therapy options for peptic ulcer
Injection
- Adreanline (constricts area)
Thermal
- heat area to damage BV
Mechanical
- Clip
Heamospray
- mineral blend powder
What is the most efficient combined endoscopic therapy
adrenaline+ thermal or clips
What are the two procedures used if bleeding cant be controlled endoscopically
angiography and embolization
laparotomy
How does endotherapy manage Upper GI bleeding Varices
Endotherapy
Oesophageal
- band ligation
- glue injection
Gastric/renal
- glue injection
How is airways protected in endotherapy
Airways are intubated
What is the 4 possible managements of Varices causing upper GI bleeding
IV terlipresson
IV broad spectrum
Correct coagulapathy
Endotherapy
Sengstaken-Blakemore tube
What is the mechanism of IV terlipressin and how does this manage varices
Is vasoconstrictor of splanchnic blood supply
- therefore reduced blood flow to portal vein
- reducing portal pressure
What is the purpose ofSengstaken-Blakemore tube
and when is it used
Transjugular intrahepatic porto-systemic shunt
Used when bleeding by varices is uncontrolled by endoscopy
