Acute GI bleed - not finished

Question 1

Define upper GI bleed.

Answer 1

Upper gastrointestinal bleeding (UGIB) refers to GI blood loss whose origin is proximal to the ligament of Treitz at the duodenojejunal junction.

Question 2

Describe the epidemiology of UGIB.

Answer 2

• UGIB results in more than 250,000 hospital admissions annually in the US, with mortality of up to 14%.
• In the UK, UGIB accounts for 70,000 hospital admissions annually, the majority of these being non-variceal in origin, with a mortality of 10%
• Mortality is secondary to hypovolaemic shock

Question 3

What are the 3 most common causes of UGIB?

Answer 3

• Peptic ulcer disease (26%)
• Gastritis/erosions (16%)
• Oesophagitis (17%)
• No cause found (12%)
• Erosive duodenitis (9%)
• Varices (8%)
• Portal hypertensive gastropathy (4%)
• Mallory-Weiss tears (3%)
• Malignancy (3%)
• Vascular ectasia (2%).

Question 4

Summarise the presentation of a UGIB.

Answer 4

• Haemodynamic compromise
• Haematemesis
• Coffee-ground emesis
• Return of bright red blood through NG tube
• Melaena
• Rare: haematochezia (bright red blood per rectum)
• BG: Varices/peptic ulcer disease(PUD)

Question 5

What are the differentials for an UGIB?

Answer 5

1. PUD
2. Oesophageal varices
3. Oesophagitis
4. Mallory-Weiss tear

Question 6

How would you distinguish between these differentials?

1. PUD
2. Oesophageal varices
3. Oesophagitis
4. Mallory-Weiss tear

Answer 6

Question 7

List some uncommon causes of UGIB.

Answer 7

• Boerhaave syndrome (spontaneous oesophageal perforation)
• Gastric varices
• Arteriovenous malformations (AVMs)
• Dieulafoy’s lesions
• Upper GI tumours
• Aortoenteric fistulae (AEF)
• Coagulopathy

Question 8

What are the two scoring systems used to assess gastrointestinal bleeding?

Answer 8

1. Glasgow-Blatchford score (pre-endoscopic)
2. Rockall score (post-endoscopic)

Question 9

Describe the two scoring systems used to assess gastrointestinal bleeding.

Answer 9

Glasgow-Blatchford bleeding score (GBS) - pre-endoscopy scoring system. Used to decide which patients need an endoscopy urgently (with 12hrs) and which are stable enough to have it done non-urgently (with 24hrs). A score of 6 or more is associated with a >50% risk of needing an intervention.

Rockall scoring system - post-endoscopic score uses clinical criteria and endoscopic findings to identify if patinet is at risk of adverse outcome after upper GI bleed. Score <3 carries good prognosis ( >8 high risk of mortality)

Question 10

Define lower gastrointestinal bleeding.

Answer 10

LGIB is any bleed originating distal to the iliocaecal valve which includes the colon, rectum and anus.

LGIB was previously defined as any bleed occurring distal to Treitz ligament but this has now been divided into middle GI bleed and lower GI bleed.

Question 11

What are the differences in incidence of LGIB and UGIB?

Answer 11

Lower GI bleeding is approximately one fifth as common as upper GI bleeding and accounts for approximately 20 to 30 hospitalisations per 100,000 adults per year.

LGIB incidence increases with age.

Question 12

What are the most common causes of acute LGIB?

Answer 12

Causing significant blood loss:

• Colonic diverticular disease
• Angiodysplasia

Causing insignificant blood loss:

• Haemorrhoids
• Colonic neoplasms

Rare: solitary rectal ulcer, vasculitis, endometriosis.

Question 13

List other causes of LGIB.

Answer 13

Anatomical abnormalities -

• Diverticuar disease (15-40% of LGIB) - common in left colon
• Meckel’s diverticulum (1-2% of population) - incomplete obilteration of vitelline duct in ileal diverticulum

Vascular

• Colonic angiodysplasia - common in right colon in elderly. Risk factors - angiodysplasia include chronic renal disease and recent anticoagulant therapy.
• Ischaemic colitis - mucosal hypoxia caused by hypoperfusion of intramural vessels caused by vessel disease
• Radiotherapy of abdominal pelvic cancers - vascular damage with subsequent mucosal ischaemia, thickening and ulceration (within 6 weeks of radiotherapy, chronic injury occurs wth 9weeks-4months after)
• Bleeding from Dieulafoy’s lesion in the colon - rare; small mucosal lesions subsequently erode an underlying vessels, leading to bleeding.
• Other: aorto-enteric fistula, vasculitis, hereditary haemorrhagic telangiectasia, blue rubber bleb nevus syndrome.

Inflammatory

• IBD including Crohn’s and UC.may present with bloody diarrhoea

Infectious

• Causes haematochezia. Most common types: Escherichia, Salmmonella, Histoplasma, Cytomegalovirus.

Neoplastic

• Colorectal cancer, colon polyps; usually painless and intermittent

Anorectal

• Internal haemorrhoids
• Solitary rectal ulcer
• Rectal varices
• Anal fissures

Miscellaneous

• Post-polypectomy bleeding
• NSAID colopathy
• Elastic tissue disorders
• Upper GI bleeding (rapid transport)
• Prostate biopsy site bleeding
• Endometriosis

Question 14

What are the differentials for a LGIB?

Answer 14

• Diverticular disease
• Colonic angiodysplasia
• Ischaemic colitis
• Crohn’s disease
• Ulcerative colitis
• Infectious colits
• Colorectal cancer
• Internal haemorrhoids
• Anal fissure
• Colonc polyps

Question 15

How do you distinguish between the differentials?

• Diverticular disease, Colonic angiodysplasia
• Ischaemic colitis
• Crohn’s disease, Ulcerative colitis
• Infectious colitis
• Colorectal cancer
• Internal haemorrhoids, Anal fissure
• Colonic polyps