Acute GI Bleed Flashcards
define an upper gastrointestinal haemorrhage
proximal to ligament treitz; stomach, oesophagus, duodenum
define lower GI haemorrhage
distal to ligament treitz; jejunum, ileum, colon
define haematemesis
vomiting fresh blood
define melaena
black tarry faeces with digested blood
what can cause gastritis and duodenitis?
> h. pylori
NSAID, aspirin
alcohol
stress / systemic illness
name the five most common causes of acute UGI haemorrhage
> peptic ulcer > oesophagitis > gastritis > erosive duodenitis > varices
what can cause oesophagitis?
> reflux > hiatus hernia > alcohol > systemic illness > bisphosphonates
why can cirrhosis lead to varices?
it causes portal hypertension
what malignancies can lead to acute UGI haemorrhage?
> oesophageal cancer
> gastric cancer
what can cause a Mallory Weiss tear?
retching and vomiting
what is the aetiology of LGI haemorrhage?
> diverticular disease > vascular malformations > ischaemic colitis > haemorrhoids > IBD > neoplasia > radiation
what is diverticular disease?
protrusion of the inner mucosal lining through the outer muscular layer forming a pouch with symptoms
what is the aim of assessment of GI haemorrhage?
> identify the sick patient with life threatening hemodynamic compromise then initiating appropriate resuscitation
identify the low risk patients the discharging them or carrying out an outpatient investigation
what may be in the presenting complaint of GI haemorrhage?
> vomiting blood > black stools > dyspepsia > dizzy, collapse > weight loss
what may be in the past medical history of GI haemorrhage?
> chronic liver disease
chronic cardiac, renal disease
malignancy
previous GI haemorrhage
what may be seen in the drug history in a GI haemorrhage?
> antiplatelets
NSAID
over the counter medication
when might an UGI haemorrhage present with fresh blood being passed in stool?
if there is rapid transit
what initial investigations should you carry out in GI haemorrhage?
> blood tests
blood gas
12 lead ECG
what blood tests do you carry out in the initial investigations of GI haemorrhage?
> FBC
U and E’s
coagulation
cross match
what scoring system is used in Aberdeen?
the Glasgow-Blatchford score
how is a Glasgow-Blatchford score of 0/1 managed?
consider outpatient investigation or discharge
how is a Glasgow-Blatchford score of 2 managed?
inpatient investigation
What percentage of patients with a score >6 are at greater risk of needing intervention?
50%
what patients are taken to the bleeding unit/HDU?
the haemodynamically compromised
what are the targets for resuscitation?
> alert
urine output
Hb 80
what fluid is used in resuscitation?
> crystalloid
> blood products
define shock
circulatory insufficiency resulting in inadequate oxygen delivery, global hypoperfusion and tissue hypoxia
what are the signs/symptoms of shock?
> tachypnoea > tachycardia > hypotension > oliguria > anxiety/confusion > cold, clammy skin
describe non-endoscopic management
> nil by mouth
stop harmful medication (antiplatelets, anticoagulation, NSAID, antihypertensive)
reversal of harmful medication
correct coagulopathy
what is the effect of early endoscopy on high risk groups?
> reduced transfusion
reduced length of stay
reduced re-bleed
reduced surgical therapy
what endoscopic therapies are there for peptic ulcers?
> Injection (adrenaline) > Thermal (gold probe) > Mechanical (clip) > Haemospray Combination therapy is most effective (adrenaline + thermal/clips)
why should you carry out a PPI infusion post endoscopic procedure?
> stabilises clot
increases gastric pH
reduces re-bleed
in what circumstances should there be a high degree of suspicion of variceal haemorrhage?
> signs of chronic liver disease
history of known liver disease
known varices
what sort of complications cause patient death in variceal haemorrhage?
> sepsis
renal failure
encephalopathy
what is the management in variceal haemorrhage?
> GCS reduction > resuscitation (avoid saline in cirrhosis) > blood products > senior support > gastroenterology
what non endoscopic management is there for variceal haemorrhage?
> terlipressin
antibiotics
sengstaken-blakemore tube
what endoscopic management is there for variceal haemorrhage?
> band ligation
glue injection
transjugular intrahepatic portosystemic shunt
what are the risk factors for the outcome of LGI haemorrhage?
> age > co-morbidity > inpatients (higher mortality rate) > initial shock > medication (aspirin and NSAIDs increase risk of LGI bleeding)
what surgical management is there for LGI haemorrhage?
> subtotal colectomy
> segmental resection
what imaging investigations should be carried out in LGI haemorrhage?
> flexible sigmoidoscopy or full colonoscopy
If no colonic cause found and UGI bleed excluded, consider small bowel origin so
CT angiogram
Meckel’s scan (scintigraphy)
Capsule endoscopy
Double balloon enteroscopy
What is the Glasgow-Blatchford score based on?
> Blood urea > Haemoglobin > Systolic blood pressure > Pulse >100 > Presentation with melaena > Presentation with syncope > Hepatic disease > Cardiac failure
