Acute GI Bleeding Flashcards
Where is upper GI bleeding?
Oesophagus, stomach and duodenum
Proximal to ligament of Trietz
Where is lower GI bleeding?
Bleeding distal to duodenum
Distal to ligament of Trietz
What is the clinical definition of upper GI bleeding?
Haematemesis, melaena, elevated urea (partially digested blood)
Associated with dyspepsia, reflux and epigastric pain
NSAID use
What is the clinical definition of lower GI bleeding?
Fresh blood/clots, magenta stools, normal urea
Typically painless and more common in advanced stage
What are some causes of upper GI bleeding?
Ulcers and inflammation
Oesophageal and gastric varices, Mallory Weiss Tear, malignancy, angiodysplasia
What are the most common causes of upper GI bleeding?
Gastric cancer
Duodenal ulcer
Mallory-Weiss tear
Oesophagitis
Oesophageal varices
What questions are asked with peptic ulcers?
If any dyspepsia, haematemesis, collapse
Past medical history - liver disease
NSAIDs
Alcohol, smoking, injecting drugs
FH - peptic ulcers and h. pylori
How is a peptic ulcer formed?
Injury to defence forces - mucus secretion and bicarbonate, submucosa damaged
Imbalance of natural defences to damaging agents
What are the risk factors for peptic ulcers?
H. pylori
NSAIDs/ Aspirin
Alcohol excess
Systemic illness
How does H. pylori cause a peptic ulcer?
H. pylori penetrates mucus layer and adheres to surface
Urease converts urea to ammonia - buffers gastric acid to protect the infection
Proliferation
Gastric ulcer formed
How does NSAIDs cause a peptic ulcer?
COX-1 inhibition - so no GI protection
COX-2 inhibition - causes increased damage and unable to heal
What should not be missed with peptic ulcers?
Gastric ulcers may sit over gastric carcinoma
Zollinger-Ellison syndrome causes recurrent poor healing duodenal ulcers due to acid overproduction
How does gastritis and duodenitis causes bleeding?
Bleed in context of impaired coagulation - medical conditions, anti-coagulants, antiplatelets
What can cause oesophagitis?
Reflux oesophagitis, hiatus hernia, alcohol, bisphosphonates, systemic illness
What increases risk of bleeding for oesophagitis?
Anti-platelets or anti-coagulation
Explain varices
Secondary to portal hypertension and usually due to liver cirrhosis
Abnormally dilated collateral vessels
Increase in portal pressure can lead to life threatening bleeding
What types of cancer can cause upper GI bleeding?
Oesophageal - typically ooze
Gastric
Describe Mallory-Weiss tear
Linear tear at oesophageal-gastric junction
Follows period of retching/vomiting
10% need endoscopic treatment
Describe diuelafoy
Submucosal arteriolar vessel eroding through mucosa
Gastric fundus
Describe angiodysplasia
Vascular malformation, occurs anywhere in GI, can cause chronic occult or overt bleeding
Associated with heart valve replacement
What are some colonic causes for acute lower GI bleeding?
Diverticular disease and haemorrhoids most common
Vascular malformations, neoplasia, ischaemic colitis, radiation enteropathy/proctitis, IBD
What investigations are need for diagnosis when lower GI bleed?
Flexible sigmoidoscopy or full colonoscopy
Explain diverticular disease
Protrusion of inner mucosal lining through the outer muscular layer forming a pouch
Diverticulosis - presence
Diverticulitis - inflammation
Risk of further bleeding
What are haemorrhoids?
Enlarged vascular cushions around anal canal
Painful if thrombosed or external
Associated with straining, constipation and low fibre diet
What is the treatment for haemorrhoids?
Elective surgical intervention
What is the treatment for angiodysplasia?
Argon phototherapy - burns off blood vessel
What is a colonic neoplasia?
Colonic polyps or carcinoma
Often preceding lower GI symptoms
Very rare to cause a life threatening bleed
Explain Ischaemic colitis
Disruption in blood supply to colon
Presents with crampy abdominal pain and self limiting
Dusky blue and swollen mucosa
What are the complications of ischaemic colitis?
Gangrene and perforation
What is radiation proctitis?
Previous history of radiotherapy
Crescendo PR bleeding
May be dependant on blood transfusions due to chronic loss
What is the treatment for radiation proctitis?
APC
Sucralfate enemas
Hyperbaric oxygen
What are some small bowel causes of acute lower GI bleeding?
Meckel’s diverticulum, angiodysplasia, tumour/GIST, small bowel ulceration and aortoentero fistulation
What investigations are used for the small bowel?
CT angiogram
Meckel’s scan
Capsule endoscopy
Double balloon enteroscopy
What is used to diagnose Meckel’s diverticulum?
Nuclear scintigraphy - radio isotope
Gastric reminant mucosa
What is involved in resuscitation of the patient?
Airway
Breathing
Circulation - IV access, blood samples, blood transfusion, catheter
Disability
Exposure
What is the definition of shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
Describe the haemorrhagic subtype
High resp. rate
A rapid pulse
Anxiety or confusion
Cool clammy skin
Low urine output
Low blood pressure
What are the classifications of shock?
1-4
Depend on volume lost, HR, RR, BP, Pulse, conscious level and urine output
What is included in the risk stratification UGIB?
Age, shock, co-morbidity, diagnosis, major stigmata pf recent haemorrhage
What is the pre-endoscopy score for the Blatchford score?
Blood urea, haemoglobin sex differences, systolic blood pressure and heart rate
Other markers - hepatic disease and cardiac failure
What is a low risk criteria for Glasgow Blatchford score?
Urea less than 6.5 mmol/l
Haemoglobin more than 130g/l (men) and 120g/l (women)
Systolic blood pressure more than 110mmHg
Pulse less than 100
Absence of melaena, syncope, cardiac failure or liver disease
What does the score for the Glasgow Blatchford test suggest?
Over or equal to 6 associated with a greater than 50% risk of needing an intervention
Scores lower than 2 consider discharge
What are more risks of lower GI bleed?
Age - occurs most often in elderly
Co-morbidity - doubles chance of severe bleed
Inpatients - rectal bleeding gives 23% mortality
Drugs - NSAIDs and aspirin
How is upper GI diagnosed and treated?
Endoscopy then once stable consider therapeutic options
How is lower GI diagnosed and treated?
Colonoscopy or CT angiogram
What medications are given as treatment for GI bleeding?
Vitamin K and maybe beriplex if on warfarin
PPI and tranexamic acid
Then possible surgery
What is the management for peptic ulcers?
Endoscopy is diagnostic
PPI
Angiography with embolization
Laparotomy
What are endoscopic therapies used for peptic ulcers?
Injection of adrenaline
Thermal - gold probe which burns blood vessel
Mechanical - clip (staples)
Combination most effective - adrenaline and thermal or clips
When is angiography and laparotomy used for peptic ulcer?
If bleeding ongoing and uncomfortable endoscopically
What is the management for varices?
Endoscopy with endo-therapy
Terlipressin, antibiotics and reverse abnormal coagulation
Sengstaken-Blakemore tube
TIPSS
What is terlipressin?
Vasoconstrictor of splanchnic blood supply
Reduces blood flow to portal vein
Reduces percentage of mortality
When is Sengstaken-Blakemore tube and TIPSS used for management?
If bleeding ongoing and uncontrollable endoscopically
For varices
Causes pressure on varices and blocks blood flow
TIPSS- shunt across portal system
