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Alimentary System > Acute GI bleeding > Flashcards

Acute GI 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

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 is the definition of haematemesis?

A

Blood is very emetic/prokinetic, more likely in oesophagus/stomach origin

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9
Q

what is the definition of melaena?

A

Blood is very prokinetic so brisk in significant bleeding, most likely upper GI tract

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10
Q

what is upper GI bleeding commonly associated with?

A

Associated with dyspepsia, reflux, epigastric pain
Non-steroidal anti-inflammatory use

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11
Q

in what age group is lower GI bleeding more common?

A

More common in advanced age

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12
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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13
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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14
Q

Are duodenal ulcers or gastric ulcers more common?

A

Duodenal ulcers (75%)

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15
Q

what are the most common causes of upper GI bleeding?

A

Gastric cancer
Duodenal ulcer
Mallory-Weiss tear
Oesophagitis
Oesophageal varices

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16
Q

What questions might you ask in the history for a peptic ulcer?

A

HPC: dyspepsia
(b) Collapse, poor urine output, large volume melaena or haematemesis

PMH: Liver disease

DH: NSAIDs incl over-the-counter, steroids
Anti-coagulants (reversal agents?), anti-platelet agents

SH: Alcohol, smoking, injecting drug use

FH: Peptic ulcers , H pylori

Weight loss raises suspicion of malignancy
NSAIDs (ibuprofen, diclofenac, celecoxib)
FH ulcers may raise suspicion of possible Helicobacter pylori

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17
Q

What are risk factors for peptic ulcers?

A

Helicobacter pylori

NSAIDs/aspirin

Alcohol excess

Systemic illness (stress ulcers)

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18
Q

How does helicobacter pylori lead to gastric ulcers?

A
  • Penetrate mucus layer and adhere to epithelial cells in gastric mucosa
  • Urease converts urea to ammonia – buffers gastric acid; Protects H. pylori
    -> Duodenal Ulceration
  • proliferation of H. pylori forming an infectious focus
  • Gastric ulcer formation due to:
    Increased acid
    Loss of mucus
    Epithelial cell inflammation and damage
    Inflammatory cell recruitment
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19
Q

How does helicobacter pylori lead to gastric ulcers?

A

H. pylori penetrate the mucus layer of host stomach and adhere the surface of gastric mucosal epithelial cells.

produce ammonia from urea by the urease, and the ammonia netralize the gastric acid to escape from elimination.

prolifirate, migrate, and finally form the infectious focus.

The gastric ulcerization is developed by destruction of mucosa, inflammation and mucosal cell death.

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

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20
Q

How does NSAIDs lead to gastric ulcers?

A

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

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21
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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22
Q

What is Zollinger-Ellison syndrome also known as?

A

Gastrin-secreting pancreatic tumour

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23
Q

How does Zollinger-Ellison syndrome impact duodenal ulcers?

A

Causes poor healing of duodenal ulcers

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24
Q

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

A

Similar risk factors to gastric and duodenal ulcer

Tend to bleed in context of impaired coagulation
Medical conditions
Anti-coagulants (warfarin, rivaroxaban, apixaban, dabigatran, LMWH)
Anti-platelets (clopidogrel, ticagrelor)

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25
Q

What tends to cause gastritis and duodenitis to bleed?

A

Medical conditions

Anti-coagulants

Anti-platelets

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26
Q

What are examples of anti-coagulants?

A

Warfarin

Rivaroxaban

Apixaban

Dabigatran

LMWH

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27
Q

What are examples of anti-platelets?

A

Clipidogrel

Ticagrelor

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28
Q

What are risk factors for oesophagitis?

A

Hiatus hernia

Alcohol

Biphosphonates

Systemic illness

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29
Q

When is oesophagitis most likely to have significant bleeding?

A

When on anti-platelets or anti-coagulants

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30
Q

What are varices secondary to?

A

Portal hypertension, usually due to liver cirrhosis

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31
Q

what are varices?

A

Abnormally dilated collateral vessels

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32
Q

What are different types of varices?

A

Oesophageal (90%)

Gastric (8%)

Rectal and splenic (rare)

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33
Q

What are examples of upper GI malignancies?

A

Oesophageal cancer

Gastric cancer

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34
Q

what can increases in portal pressure (eg infection/drug use) lead to?

A

Increases in portal pressure (eg infection/drug use) can lead to life threatening bleeding

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35
Q

What is a Mallory-Weiss tear?

A

Linear tear at oesophageal-gastric junction

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36
Q

What does a Mallory-Weiss tear follow a period of?

A

Vomiting and retching

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37
Q

oesophageal cancer presentation

A

May have dysphagia /weight loss history
Typically “ooze”

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38
Q

gastric cancer presentation

A

Can present as an ulcer
GU needs interval endoscopy for healing

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39
Q

Up to 10% of what significant requiring endoscopic treatment?

A

Mallory-Weiss tear

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40
Q

What is Diuelafoy?

A

Submucosal arteriolar vessel eroding through mucosa

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41
Q

Where does Diuelafoy commonly occur?

A

Gastric fundus

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42
Q

What is an angiodysplasia?

A

Vascular malformation

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43
Q

Where can an angiodysplasia occur?

A

Anywhere along the GI tract

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44
Q

What chronic conditions is angiodysplasia associated with?

A

Heart valve replacement

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45
Q

what is angiodysplasia a frequent cause of?

A

Frequent cause of chronic occult or overt occult bleeding

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46
Q

What investigation is done for upper GI bleeding?

A

upper endoscopy

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47
Q

When should an endoscopy be done for an upper GI bleed?

A

Within 24 hours, sooner if unstable

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48
Q

What are some colonic causes of lower GI bleeding?

A

Diverticular disease

Haemorrhoids

Vascular malformation (angiodysplasia)

Neoplasia (carcinoma or polyps)

Ischaemic colitis

Radiation enteropathy/proctitis

IBD (such as ulcerative colitis or Crohn’s disease)

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49
Q

What does diagnosis of a lower GI bleed require?

A

Flexible sigmoidoscopy or full colonoscopy

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50
Q

What is diverticular disease?

A

Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch

51
Q

what does diagnosis of acute lower GI bleeding require?

A

Diagnosis requires flexible sigmoidoscopy or full colonoscopy

52
Q

What is diverticular disease?

A

Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch

53
Q

What does diverticulosis mean?

A

Presence

54
Q

What does diverticulitis mean?

A

Inflammation

55
Q

What is the main risk of diverticular disease

A

Bleeding occurs in 10-20% during the lifetime
10% chance of recurrence at one year and 25% at four years.

Risk of further bleeding

56
Q

What are haemorrhoids?

A

Enlarged vascular cushions around anal canal

Painful if thrombosed or external

Association with straining/constipation/low fibre diet

57
Q

When are haemorrhoids painful?

A

if thrombosed or external

58
Q

What are haemorrhoids associated with?

A

straining/constipation/low fibre diet

59
Q

What is the treatment for haemorrhoids?

A

elective surgical intervention

60
Q

What is bleeding due to angiodysplasia often precipitated by?

A

Bleeding often precipitated by anticoagulants/antiplatelets

61
Q

What is the treatment for angiodysplasia?

A

Argon Phototherapy

62
Q

what is angiodysplasia?

A

Vascular malformation
Degeneration
Friable and bleeds easily
May be association with valvular abnormalities

63
Q

What are different kinds of colonic neoplasia?

A

Colonic polyps or carcinoma

64
Q

what is colonic neoplasia often preceded by?

A

lower GI symptoms
Very rare to cause life-threatening bleeding

65
Q

What is ischaemic colitis?

A

disruption in blood supply to colon

Affects areas according to blood supply, typically descending/sigmoid colon

66
Q

What determines what area of the colon ischaemic colitis affects?

A

Affects areas according to blood supply, typically descending/sigmoid colon

67
Q
A
68
Q

What does ischaemic colitis typically affect?

A

typically descending/sigmoid colon

69
Q

What are possible complications of ischaemic colitis?

A

gangrene and perforation

70
Q

What is usually present in radiation proctitis?

A

Crescendo PR bleeding
May be dependent on blood transfusions due to chronic loss

71
Q

what is the presentation of ischaemic colitis?

A

crampy abdominal pain
Dusky blue, swollen mucosa

72
Q

who does ischaemic colitis most commonly affect?

A

More common over 60 years

73
Q

What is the treatment for radiation proctitis?

A

APC
Sulcrafate enemas
Hyperbaric oxygen

74
Q

what does treatment of IBD depend on?

A

blood transfusions due to chronic loss

75
Q

what previous history will patients presenting with radiation proctitis have?

A

previous history of radiotherapy
Cervical cancer
Prostate cancer

76
Q

describe IBD?

A

Ulcerative colitis or Crohn’s disease of colon

Slower onset with diarrhoea symptoms

Treatment depends on extent/severity

77
Q

what are some causes of small bowel bleeding?

A

Meckel’s diverticulum
Small bowel angiodysplasia
Small bowel tumour/GIST
Small bowel ulceration (NSAID associated)
Aortoentero fistulation – following AAA repair

78
Q

When should small bowel origin of bleeding be considered?

A

If no colonic cause is found and upper GI bleeding excluded need to consider small bowel origin (5%)

79
Q

What percentage of GI bleeds are small bowel?

A

5%

80
Q

What investigations can be done to look at bleeding in the small bowel?

A

CT angiogram
Meckel’s scan (Scintigraphy)
Capsule endoscopy
Double balloon enteroscopy

81
Q

What is Meckel’s diverticulum?

A

an outpouching or bulge in the lower part of the small intestine. The bulge is congenital (present at birth) and is a leftover of the umbilical cord.

82
Q

What is used to diagnose Meckel’s diverticulum?

A

Nuclear Scintigraphy

With acid secretion from gastric tissue, small bowel ulceration can occur leading to bleeding.
Scintigraphy uses radioisotope labelling to detect the gastric mucosa.

83
Q

What is gastrointestinal bleeding managed by?

A

Resuscitation
Airway
Breathing
Circulation
Wide bored IV access => IV fluids
Urgent blood samples to lab: FBC, UE, LFT, Coagulation, blood group and save/ cross match
Blood transfusion if Hb<7g/dl or ongoing active bleeding
Catheter
Disability
Exposure

84
Q

What management in terms of circulation is done for gastrointestinal bleeding?

A

Wide bored IV access => IV fluids
Urgent blood samples to lab: FBC, UE, LFT, Coagulation, blood group and save/ cross match
Blood transfusion if Hb<7g/dl or ongoing active bleeding

85
Q

When is a blood transfusion given for gastrointestinal bleeding?

A

if Hb<7g/dl or ongoing active bleeding

86
Q

what is shock?

A

Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia

87
Q

What is the clinical presentation of shock?

A

a high respiratory rate (tachypnoea)
a rapid pulse (tachycardia)
anxiety or confusion
cool clammy skin
low urine output (oliguria)
low blood pressure (hypotension)

88
Q

What are the different stages of shock?

A

stage 1-4

89
Q

describe stage 1 of shock

A

Volume lost
% Blood loss
RR
HR
BP
Pulse pressure
Conscious level
Urine output

<750ml
<15%
<20
<100
Normal
Normal
Normal/
anxious
>30ml/h

90
Q

describe stage 2 of shock

A

Volume lost
% Blood loss
RR
HR
BP
Pulse pressure
Conscious level
Urine output

750-1500ml
15-30%
20-30
100-120
Normal
Decreased
Agitated
20-30ml/h

91
Q

describe stage 3 of shock

A

Volume lost
% Blood loss
RR
HR
BP
Pulse pressure
Conscious level
Urine output

1500-2000ml
30-40%
30-40
120-140
Low
Decreased
Confused
5-15ml/h

92
Q

describe stage 4 classification of shock?

A

Volume lost
% Blood loss
RR
HR
BP
Pulse pressure
Conscious level
Urine output

> 2000ml
40%
40
140
Low
Decreased
Confused/
drowsy
0

93
Q

What does the management of GI bleeding involve?

A

Resuscitation
Risk stratification - ? Critical care placement
Diagnosis + treatment
Upper GI: Endoscopy – once stable, within 24 hours
-> therapeutic options
Lower GI: ? Colonoscopy or CT angiogram – depending on bleeding severity
Withhold/reverse contributory medications as able*
Vitamin K +/- beriplex if on warfarin
Specific medications
PPI
Tranexamic acid??
Consider CT angiography/interventional radiology/surgical interventions as appropriate

*re-commencing required medications once haemostasis achieved

94
Q

what risk stratification score is used for acute GI bleeding?

A

Risk Stratification UGIB: Rockall Score

95
Q

what are the components of rockall score?

A

Age
Shock
Co-morbidity
Diagnosis
Major stigmata of recent haemorrhage

96
Q

what would be a score of 0 on the rockall score?

A

<60
No Shock
No major co-morbidity
MWT,
No lesion identified
No SRH
None or dark spot only

97
Q

what would be a score of 1 on the rockall score?

A

60-79
Tachycardia HR>100
BP>100 mm Hg

All other diagnoses

98
Q

what would be a score of 2 on the rockall score?

A

> 80
Hypotension
HR>100
BP <100mm Hg
Cardiac failure, IHD, any major co-morbidity
Malignancy of upper GI tract
Blood in upper GI tract
Adherent clot
Visible vessel Spurting vessel

99
Q

what would be a score of 3 on the rockall score?

A

renal failure, liver failure, disseminated cancer

100
Q

Other than Rockall score, what else can be used to risk stratification of upper GI bleeding?

A

Blatchford Score

101
Q

What things are considered for the blatchford score?

A

Pre-endoscopy score:
Blood urea (mmol/L)
Haemoglobin sex differences (g/L)
Systolic blood pressure (mm Hg)
Heart rate

Other markers
Collapse
Melaena
Hepatic disease
Cardiac failure

102
Q

What is low risk criteria for Glasgow blatchford score?

A

Low-risk criteria of Glasgow Blatchford Score
urea <6·5 mmol/L
haemoglobin >=130 g/L (men) or >=120 g/L (women)
systolic blood pressure >=110 mm Hg
pulse <100 beats per min
absence of melaena, syncope, cardiac failure, or liver disease

103
Q

What score for the blatchford score is associated with greater than 50% risk of needing an intervention?

A

Scores ≥6 associated with a greater than 50% risk of needing an intervention

104
Q

wat score on the blatchford score would consider discharge +/- outpatient investigations?

A

scores <2

105
Q

What scoring system is used for risk stratification of lower GI bleeding?

A

No validated scoring systems

106
Q

Is the relationship between age and mortality more defined in lower or upper GI bleeding?

A

more defined in upper GI bleeding

107
Q

What is the relationship between co-morbidity and severe bleed?

A

Presence of 2 co-morbid conditions doubles the chance of a severe blee

108
Q

How does inpatients who have rectal bleeding impact mortality?

A

Inpatients who have rectal bleeding have a 23% mortality compared to 3.6%

109
Q

How do drugs impact the risk of lower GI bleeding?

A

Patients taking Aspirin and NSAIDs are at increased risk of lower GI bleeding, OR 1.8-2.7

110
Q

what are important predictors of subsequent severe bleeding

A

initial shock and gross rectal bleeding

111
Q

What is the benefit of using dedicated teams to manage acute GI bleeding?

A

Improved mortality in patients with acute gastrointestinal bleeding who are managed by dedicated teams
Improved outcome due to protocolised care, prompt resuscitation and close medical and surgical liaison

112
Q

Why does having dedicated teams improve the outcome of acute GI bleeding?

A

protocolised care, prompt resuscitation and close medical and surgical liaison

113
Q

What is the management of a peptic ulcer?

A

Endoscopy

Proton pump inhibitors

Angiography with embolization

Laparotomy

114
Q

What are management options of GI bleeding due to Peptic Ulcer?

A

Endoscopy
Diagnostic
Identify those at high risk of further bleeding
Endotherapy
Proton pump inhibitors

Angiography with embolization

Laparotomy

115
Q

What are endoscopic therapy to pathology options for the management of a peptic ulcer?

A

Injection
Adrenaline 1:10000
Thermal
Contact – “gold probe”
Mechanical
Clip

Combination therapy most effective (adrenaline + thermal or clips)

116
Q

What is the management for a peptic ulcer when bleeding is uncontrollable?

A

angiography with embolisation
laparotomy

117
Q

What are endoscopic therapy to pathology options for the management of a peptic ulcer?

A

Injection
Adrenaline 1:10000
Thermal
Contact – “gold probe”
Mechanical
Clip

Combination therapy most effective (adrenaline + thermal or clips)

118
Q

What is the management of varices?

A

Endoscopy with endotherapy
Ideally intubated with airway protected

Terlipressin
Antibiotics
Reverse abnormal coagulation

Sengstaken-Blakemore tube
TIPSS

119
Q

What are different kinds of endotherapy for oesophageal varices?

A

Band ligation
Glue injection

120
Q

What are different kinds of endotherapy for gastric varices?

A

Glue injection

121
Q

What are different kinds of endotherapy for rectal varices?

A

Glue injection

122
Q

What is the management of varices if bleeding uncontrollable endoscopically?

A

Sengstaken-Blakemore tube
TIPSS - Transjugular intrahepatic porto-systemic shunt (TIPSS)

123
Q

Acute Gastrointestinal bleeding

A

Variety of causes both upper and lower
Good clinical history is useful is predicting diagnosis and outcomes
Essential to undertake thorough clinical assessment and escalate care as appropriate
Endoscopy is both diagnostic and therapeutic in many cases

Alimentary System (44 decks)

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