Acute GI bleeding Flashcards
What is the incidence of GI bleed in the UK?
180/100000
What is the overall mortality of acute GI bleed?
10%
What mainly affects the outcomes of GI bleed?
Identification and promp management
Where can upper GI bleeding occur from?
A
Oesophagus
Stomach
Duodenum
anywhere proximal to ligament of Trietz
Where can lower GI bleeding occur from?
Bleeding distal to duodenum (jejunum, ileum, colon)
Distal to ligament of Trietz
What is the clinical presentation of upper GI bleed?
Haematemesis
Melaena
Elevated urea (digested blood turns haem into urea)
Dyspepsia, reflux, epigastric pain
What is the clinical presentation of lower GI bleeding?
Fresh blood/clots
Magenta stools
Normal urea (rarely elevated if proximal small bowel origin)
Typically painless
what is the definition of haematemesis?
Blood is very emetic/prokinetic, more likely in oesophagus/stomach origin
what is the definition of melaena?
Blood is very prokinetic so brisk in significant bleeding, most likely upper GI tract
what is upper GI bleeding commonly associated with?
Associated with dyspepsia, reflux, epigastric pain
Non-steroidal anti-inflammatory use
in what age group is lower GI bleeding more common?
More common in advanced age
What can cause upper GI bleeds in the oesophagus?
Oesophageal ulcer
Oesophagitis
Oesophageal varices
Mallory Weiss Tear
Oesophageal malignancy
What can cause upper GI bleeds in the stomach?
Gastric ulcer
Gastritis
Gastric varices
Portal hypertensive gastropathy
Gastric malignancy
Dieulafoy
Angiodysplasia
Are duodenal ulcers or gastric ulcers more common?
Duodenal ulcers (75%)
what are the most common causes of upper GI bleeding?
Gastric cancer
Duodenal ulcer
Mallory-Weiss tear
Oesophagitis
Oesophageal varices
What questions might you ask in the history for a peptic ulcer?
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
What are risk factors for peptic ulcers?
Helicobacter pylori
NSAIDs/aspirin
Alcohol excess
Systemic illness (stress ulcers)
How does helicobacter pylori lead to gastric ulcers?
- 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
How does helicobacter pylori lead to gastric ulcers?
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
How does NSAIDs lead to gastric ulcers?
Prostaglandin production -> reduces mucus and bicarbonate excretion -> reduces physical defences
Why when a gastric ulcer is present is a repeat endoscopy indicated at 8 weeks?
They may have been sitting over a gastric carcinoma
What is Zollinger-Ellison syndrome also known as?
Gastrin-secreting pancreatic tumour
How does Zollinger-Ellison syndrome impact duodenal ulcers?
Causes poor healing of duodenal ulcers
What are the risk factors for gastritis and duodenitis similar to?
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)
What tends to cause gastritis and duodenitis to bleed?
Medical conditions
Anti-coagulants
Anti-platelets
What are examples of anti-coagulants?
Warfarin
Rivaroxaban
Apixaban
Dabigatran
LMWH
What are examples of anti-platelets?
Clipidogrel
Ticagrelor
What are risk factors for oesophagitis?
Hiatus hernia
Alcohol
Biphosphonates
Systemic illness
When is oesophagitis most likely to have significant bleeding?
When on anti-platelets or anti-coagulants
What are varices secondary to?
Portal hypertension, usually due to liver cirrhosis
what are varices?
Abnormally dilated collateral vessels
What are different types of varices?
Oesophageal (90%)
Gastric (8%)
Rectal and splenic (rare)
What are examples of upper GI malignancies?
Oesophageal cancer
Gastric cancer
what can increases in portal pressure (eg infection/drug use) lead to?
Increases in portal pressure (eg infection/drug use) can lead to life threatening bleeding
What is a Mallory-Weiss tear?
Linear tear at oesophageal-gastric junction
What does a Mallory-Weiss tear follow a period of?
Vomiting and retching
oesophageal cancer presentation
May have dysphagia /weight loss history
Typically “ooze”
gastric cancer presentation
Can present as an ulcer
GU needs interval endoscopy for healing
Up to 10% of what significant requiring endoscopic treatment?
Mallory-Weiss tear
What is Diuelafoy?
Submucosal arteriolar vessel eroding through mucosa
Where does Diuelafoy commonly occur?
Gastric fundus
What is an angiodysplasia?
Vascular malformation
Where can an angiodysplasia occur?
Anywhere along the GI tract
What chronic conditions is angiodysplasia associated with?
Heart valve replacement
what is angiodysplasia a frequent cause of?
Frequent cause of chronic occult or overt occult bleeding
What investigation is done for upper GI bleeding?
upper endoscopy
When should an endoscopy be done for an upper GI bleed?
Within 24 hours, sooner if unstable
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)
What does diagnosis of a lower GI bleed require?
Flexible sigmoidoscopy or full colonoscopy
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
what does diagnosis of acute lower GI bleeding require?
Diagnosis requires flexible sigmoidoscopy or full colonoscopy
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
What does diverticulosis mean?
Presence
What does diverticulitis mean?
Inflammation
What is the main risk of diverticular disease
Bleeding occurs in 10-20% during the lifetime
10% chance of recurrence at one year and 25% at four years.
Risk of further bleeding
What are haemorrhoids?
Enlarged vascular cushions around anal canal
Painful if thrombosed or external
Association with straining/constipation/low fibre diet
When are haemorrhoids painful?
if thrombosed or external
What are haemorrhoids associated with?
straining/constipation/low fibre diet
What is the treatment for haemorrhoids?
elective surgical intervention
What is bleeding due to angiodysplasia often precipitated by?
Bleeding often precipitated by anticoagulants/antiplatelets
What is the treatment for angiodysplasia?
Argon Phototherapy
what is angiodysplasia?
Vascular malformation
Degeneration
Friable and bleeds easily
May be association with valvular abnormalities
What are different kinds of colonic neoplasia?
Colonic polyps or carcinoma
what is colonic neoplasia often preceded by?
lower GI symptoms
Very rare to cause life-threatening bleeding
What is ischaemic colitis?
disruption in blood supply to colon
Affects areas according to blood supply, typically descending/sigmoid colon
What determines what area of the colon ischaemic colitis affects?
Affects areas according to blood supply, typically descending/sigmoid colon
What does ischaemic colitis typically affect?
typically descending/sigmoid colon
What are possible complications of ischaemic colitis?
gangrene and perforation
What is usually present in radiation proctitis?
Crescendo PR bleeding
May be dependent on blood transfusions due to chronic loss
what is the presentation of ischaemic colitis?
crampy abdominal pain
Dusky blue, swollen mucosa
who does ischaemic colitis most commonly affect?
More common over 60 years
What is the treatment for radiation proctitis?
APC
Sulcrafate enemas
Hyperbaric oxygen
what does treatment of IBD depend on?
blood transfusions due to chronic loss
what previous history will patients presenting with radiation proctitis have?
previous history of radiotherapy
Cervical cancer
Prostate cancer
describe IBD?
Ulcerative colitis or Crohn’s disease of colon
Slower onset with diarrhoea symptoms
Treatment depends on extent/severity
what are some causes of small bowel bleeding?
Meckel’s diverticulum
Small bowel angiodysplasia
Small bowel tumour/GIST
Small bowel ulceration (NSAID associated)
Aortoentero fistulation – following AAA repair
When should small bowel origin of bleeding be considered?
If no colonic cause is found and upper GI bleeding excluded need to consider small bowel origin (5%)
What percentage of GI bleeds are small bowel?
5%
What investigations can be done to look at bleeding in the small bowel?
CT angiogram
Meckel’s scan (Scintigraphy)
Capsule endoscopy
Double balloon enteroscopy
What is Meckel’s diverticulum?
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.
What is used to diagnose Meckel’s diverticulum?
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.
What is gastrointestinal bleeding managed by?
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
What management in terms of circulation is done for gastrointestinal bleeding?
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
When is a blood transfusion given for gastrointestinal bleeding?
if Hb<7g/dl or ongoing active bleeding
what is shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
What is the clinical presentation of shock?
a high respiratory rate (tachypnoea)
a rapid pulse (tachycardia)
anxiety or confusion
cool clammy skin
low urine output (oliguria)
low blood pressure (hypotension)
What are the different stages of shock?
stage 1-4
describe stage 1 of shock
Volume lost
% Blood loss
RR
HR
BP
Pulse pressure
Conscious level
Urine output
<750ml
<15%
<20
<100
Normal
Normal
Normal/
anxious
>30ml/h
describe stage 2 of shock
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
describe stage 3 of shock
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
describe stage 4 classification of shock?
Volume lost
% Blood loss
RR
HR
BP
Pulse pressure
Conscious level
Urine output
> 2000ml
40%
40
140
Low
Decreased
Confused/
drowsy
0
What does the management of GI bleeding involve?
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
what risk stratification score is used for acute GI bleeding?
Risk Stratification UGIB: Rockall Score
what are the components of rockall score?
Age
Shock
Co-morbidity
Diagnosis
Major stigmata of recent haemorrhage
what would be a score of 0 on the rockall score?
<60
No Shock
No major co-morbidity
MWT,
No lesion identified
No SRH
None or dark spot only
what would be a score of 1 on the rockall score?
60-79
Tachycardia HR>100
BP>100 mm Hg
All other diagnoses
what would be a score of 2 on the rockall score?
> 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
what would be a score of 3 on the rockall score?
renal failure, liver failure, disseminated cancer
Other than Rockall score, what else can be used to risk stratification of upper GI bleeding?
Blatchford Score
What things are considered for the blatchford score?
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
What is low risk criteria for Glasgow blatchford score?
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
What score for the blatchford score is associated with greater than 50% risk of needing an intervention?
Scores ≥6 associated with a greater than 50% risk of needing an intervention
wat score on the blatchford score would consider discharge +/- outpatient investigations?
scores <2
What scoring system is used for risk stratification of lower GI bleeding?
No validated scoring systems
Is the relationship between age and mortality more defined in lower or upper GI bleeding?
more defined in upper GI bleeding
What is the relationship between co-morbidity and severe bleed?
Presence of 2 co-morbid conditions doubles the chance of a severe blee
How does inpatients who have rectal bleeding impact mortality?
Inpatients who have rectal bleeding have a 23% mortality compared to 3.6%
How do drugs impact the risk of lower GI bleeding?
Patients taking Aspirin and NSAIDs are at increased risk of lower GI bleeding, OR 1.8-2.7
what are important predictors of subsequent severe bleeding
initial shock and gross rectal bleeding
What is the benefit of using dedicated teams to manage acute GI bleeding?
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
Why does having dedicated teams improve the outcome of acute GI bleeding?
protocolised care, prompt resuscitation and close medical and surgical liaison
What is the management of a peptic ulcer?
Endoscopy
Proton pump inhibitors
Angiography with embolization
Laparotomy
What are management options of GI bleeding due to Peptic Ulcer?
Endoscopy
Diagnostic
Identify those at high risk of further bleeding
Endotherapy
Proton pump inhibitors
Angiography with embolization
Laparotomy
What are endoscopic therapy to pathology options for the management of a peptic ulcer?
Injection
Adrenaline 1:10000
Thermal
Contact – “gold probe”
Mechanical
Clip
Combination therapy most effective (adrenaline + thermal or clips)
What is the management for a peptic ulcer when bleeding is uncontrollable?
angiography with embolisation
laparotomy
What are endoscopic therapy to pathology options for the management of a peptic ulcer?
Injection
Adrenaline 1:10000
Thermal
Contact – “gold probe”
Mechanical
Clip
Combination therapy most effective (adrenaline + thermal or clips)
What is the management of varices?
Endoscopy with endotherapy
Ideally intubated with airway protected
Terlipressin
Antibiotics
Reverse abnormal coagulation
Sengstaken-Blakemore tube
TIPSS
What are different kinds of endotherapy for oesophageal varices?
Band ligation
Glue injection
What are different kinds of endotherapy for gastric varices?
Glue injection
What are different kinds of endotherapy for rectal varices?
Glue injection
What is the management of varices if bleeding uncontrollable endoscopically?
Sengstaken-Blakemore tube
TIPSS - Transjugular intrahepatic porto-systemic shunt (TIPSS)
Acute Gastrointestinal bleeding
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
