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The Alimentary Canal > Acute GI Bleeding > Flashcards

Acute GI Bleeding Flashcards

1
Q

Where is upper GI bleeding?

A

Oesophagus, stomach and duodenum
Proximal to ligament of Trietz

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2
Q

Where is lower GI bleeding?

A

Bleeding distal to duodenum
Distal to ligament of Trietz

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3
Q

What is the clinical definition of upper GI bleeding?

A

Haematemesis, melaena, elevated urea (partially digested blood)
Associated with dyspepsia, reflux and epigastric pain
NSAID use

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4
Q

What is the clinical definition of lower GI bleeding?

A

Fresh blood/clots, magenta stools, normal urea
Typically painless and more common in advanced stage

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5
Q

What are some causes of upper GI bleeding?

A

Ulcers and inflammation
Oesophageal and gastric varices, Mallory Weiss Tear, malignancy, angiodysplasia

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6
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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7
Q

What questions are asked with peptic ulcers?

A

If any dyspepsia, haematemesis, collapse
Past medical history - liver disease
NSAIDs
Alcohol, smoking, injecting drugs
FH - peptic ulcers and h. pylori

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8
Q

How is a peptic ulcer formed?

A

Injury to defence forces - mucus secretion and bicarbonate, submucosa damaged
Imbalance of natural defences to damaging agents

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9
Q

What are the risk factors for peptic ulcers?

A

H. pylori
NSAIDs/ Aspirin
Alcohol excess
Systemic illness

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10
Q

How does H. pylori cause a peptic ulcer?

A

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

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11
Q

How does NSAIDs cause a peptic ulcer?

A

COX-1 inhibition - so no GI protection
COX-2 inhibition - causes increased damage and unable to heal

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12
Q

What should not be missed with peptic ulcers?

A

Gastric ulcers may sit over gastric carcinoma
Zollinger-Ellison syndrome causes recurrent poor healing duodenal ulcers due to acid overproduction

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13
Q

How does gastritis and duodenitis causes bleeding?

A

Bleed in context of impaired coagulation - medical conditions, anti-coagulants, antiplatelets

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14
Q

What can cause oesophagitis?

A

Reflux oesophagitis, hiatus hernia, alcohol, bisphosphonates, systemic illness

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15
Q

What increases risk of bleeding for oesophagitis?

A

Anti-platelets or anti-coagulation

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16
Q

Explain varices

A

Secondary to portal hypertension and usually due to liver cirrhosis
Abnormally dilated collateral vessels
Increase in portal pressure can lead to life threatening bleeding

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17
Q

What types of cancer can cause upper GI bleeding?

A

Oesophageal - typically ooze
Gastric

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18
Q

Describe Mallory-Weiss tear

A

Linear tear at oesophageal-gastric junction
Follows period of retching/vomiting
10% need endoscopic treatment

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19
Q

Describe diuelafoy

A

Submucosal arteriolar vessel eroding through mucosa
Gastric fundus

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20
Q

Describe angiodysplasia

A

Vascular malformation, occurs anywhere in GI, can cause chronic occult or overt bleeding
Associated with heart valve replacement

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21
Q

What are some colonic causes for acute lower GI bleeding?

A

Diverticular disease and haemorrhoids most common
Vascular malformations, neoplasia, ischaemic colitis, radiation enteropathy/proctitis, IBD

22
Q

What investigations are need for diagnosis when lower GI bleed?

A

Flexible sigmoidoscopy or full colonoscopy

23
Q

Explain diverticular disease

A

Protrusion of inner mucosal lining through the outer muscular layer forming a pouch
Diverticulosis - presence
Diverticulitis - inflammation
Risk of further bleeding

24
Q

What are haemorrhoids?

A

Enlarged vascular cushions around anal canal
Painful if thrombosed or external
Associated with straining, constipation and low fibre diet

25
Q

What is the treatment for haemorrhoids?

A

Elective surgical intervention

26
Q

What is the treatment for angiodysplasia?

A

Argon phototherapy - burns off blood vessel

27
Q

What is a colonic neoplasia?

A

Colonic polyps or carcinoma
Often preceding lower GI symptoms
Very rare to cause a life threatening bleed

28
Q

Explain Ischaemic colitis

A

Disruption in blood supply to colon
Presents with crampy abdominal pain and self limiting
Dusky blue and swollen mucosa

29
Q

What are the complications of ischaemic colitis?

A

Gangrene and perforation

30
Q

What is radiation proctitis?

A

Previous history of radiotherapy
Crescendo PR bleeding
May be dependant on blood transfusions due to chronic loss

31
Q

What is the treatment for radiation proctitis?

A

APC
Sucralfate enemas
Hyperbaric oxygen

32
Q

What are some small bowel causes of acute lower GI bleeding?

A

Meckel’s diverticulum, angiodysplasia, tumour/GIST, small bowel ulceration and aortoentero fistulation

33
Q

What investigations are used for the small bowel?

A

CT angiogram
Meckel’s scan
Capsule endoscopy
Double balloon enteroscopy

34
Q

What is used to diagnose Meckel’s diverticulum?

A

Nuclear scintigraphy - radio isotope
Gastric reminant mucosa

35
Q

What is involved in resuscitation of the patient?

A

Airway
Breathing
Circulation - IV access, blood samples, blood transfusion, catheter
Disability
Exposure

36
Q

What is the definition of shock?

A

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

37
Q

Describe the haemorrhagic subtype

A

High resp. rate
A rapid pulse
Anxiety or confusion
Cool clammy skin
Low urine output
Low blood pressure

38
Q

What are the classifications of shock?

A

1-4
Depend on volume lost, HR, RR, BP, Pulse, conscious level and urine output

39
Q

What is included in the risk stratification UGIB?

A

Age, shock, co-morbidity, diagnosis, major stigmata pf recent haemorrhage

40
Q

What is the pre-endoscopy score for the Blatchford score?

A

Blood urea, haemoglobin sex differences, systolic blood pressure and heart rate
Other markers - hepatic disease and cardiac failure

41
Q

What is a low risk criteria for Glasgow Blatchford score?

A

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

42
Q

What does the score for the Glasgow Blatchford test suggest?

A

Over or equal to 6 associated with a greater than 50% risk of needing an intervention
Scores lower than 2 consider discharge

43
Q

What are more risks of lower GI bleed?

A

Age - occurs most often in elderly
Co-morbidity - doubles chance of severe bleed
Inpatients - rectal bleeding gives 23% mortality
Drugs - NSAIDs and aspirin

44
Q

How is upper GI diagnosed and treated?

A

Endoscopy then once stable consider therapeutic options

45
Q

How is lower GI diagnosed and treated?

A

Colonoscopy or CT angiogram

46
Q

What medications are given as treatment for GI bleeding?

A

Vitamin K and maybe beriplex if on warfarin
PPI and tranexamic acid
Then possible surgery

47
Q

What is the management for peptic ulcers?

A

Endoscopy is diagnostic
PPI
Angiography with embolization
Laparotomy

48
Q

What are endoscopic therapies used for peptic ulcers?

A

Injection of adrenaline
Thermal - gold probe which burns blood vessel
Mechanical - clip (staples)
Combination most effective - adrenaline and thermal or clips

49
Q

When is angiography and laparotomy used for peptic ulcer?

A

If bleeding ongoing and uncomfortable endoscopically

50
Q

What is the management for varices?

A

Endoscopy with endo-therapy
Terlipressin, antibiotics and reverse abnormal coagulation
Sengstaken-Blakemore tube
TIPSS

51
Q

What is terlipressin?

A

Vasoconstrictor of splanchnic blood supply
Reduces blood flow to portal vein
Reduces percentage of mortality

52
Q

When is Sengstaken-Blakemore tube and TIPSS used for management?

A

If bleeding ongoing and uncontrollable endoscopically
For varices
Causes pressure on varices and blocks blood flow
TIPSS- shunt across portal system

The Alimentary Canal (33 decks)

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