Acute GI Bleeding Flashcards
What is the ligament of Treitz?
Connects small bowel to the lower part of the greater curvature of the stomach.
This creates a bend in the small intestine which proximally is the ascending duodenum and distally is the jejunum.
Where does Upper GI bleeding occur?
Proximal to the ligament of Treitz.
Oesophagus, stomach and duodenum
Where does lower GI bleeding occur?
Distal to the ligament of Treitz.
Small bowel and colon
What are signs of upper GI bleeding?
Usually fresh haematemesis or ?coffee ground vomiting
Malaena
Dyspeptic Symptoms
Epigastric Pain
NSAIDs, Aspirin, Clopidogrel, Warfarin, Brufen
Endoscopy
Elevated Urea
What are the signs of lower GI bleeding?
Usually BUT NOT ALWAYS fresh or altered blood
Age- more common with increasing age
Endoscopy
Normal Urea
What is haematemesis?
Vomiting of Blood
Bright red haematemesis = active haemorrhage from the oesophagus, stomach or duodenum
What is coffee ground vomit?
Vomiting of brown-black material which is assumed to be blood.
- Recent study using ARI bleeding unit found poor correlation between coffee ground vomit and endoscopic findings
- More suggestive of systemic illness, is associated with poor outcome in >50yrs
What is malaena?
Passage of black, tarry, loose stools per rectum
Considered to be partially digested blood
Acute upper GI bleeding
Occasionally from bleeding within the small bowel or right side of colon
What is Hematochezia?
Passage of fresh or altered stool per rectum
May be from upper GI cause (“fast transit”) or lower GI
What are some of the causes of GI bleeding?
Peptic Ulcer (GU/DU) = 44% Gastritis/Erosions = 26% Oesophagitis = 28% Erosive duodenitis = 15% Varices = 13% Malignancy = 5%
No cause found = 20%
What are the risk factors for peptic ulcer and what are the risk factors similar to?
Helicobacter Pylori
NSAIDs/Aspirin
Alcohol excess
Systemic illness
Similar risk factors for gastritis and duodenitis
Whats more common GU or DU?
DU (75%)
Rarely zollinger-ellison syndrome
-Gastrin secreting pancreatic tumour
What may gastric ulcers overly?
Gastric carcinoma
Give some causes of oesophagitis
Reflux oesophagitis Hiatus hernia Alcohol Biphosphonates Systemic illness
Describe Varices
Secondary to portal hypertension, usually due to liver cirrhosis
Abnormally dilated collateral vessels
Most commonly oesophageal (90%), but also gastric (8%), rectal and splenic
Increases in portal pressure (e.g. infection/drug use) can lead to life threatening bleeding
What is a Mallory Weiss Tear?
Linear tear in the lower oesophagus
Follows recurrent retching and vomiting
Bleeding stops spontaneously in 80-90% of patients
Haemodynamic instability and shock may occur in up to 10% of patients
What features may you see in an upper GI bleeding history?
Vomiting blood/black fluid Passing black stools (malaena) Abdominal pain (PU) Drugs: -Anti-platelets (aspirin, clopidogrel, Ticagrelor) -Anticoagulants (LMWH, Warfarin, Rivaroxiban, Dabigatran) -NSAIDs (Ibuprofen, Diclofenac) -Dizzy/collapse -Poor urine output
What are some important clues in the history of upper GI bleeding?
Alcohol excess Known liver disease Weight loss Reflux/dyspeptic history Medications
What investigations would you carry out in Upper GI bleeding?
Full blood count Urea electrolytes LFT Coagulation Blood group and x match
What are you looking for in an upper GI bleeding examination?
Signs of liver disease (varices)
Telangiectasia/cardiac disease (angiodysplasia)
Lymphadenopathy/ hepatomegaly (malignancy)
What is the management of upper GI bleeding?
Resuscitation/ Identification of shock
Consider blood transfusion =/- platelets /FFP
Risk stratification
Management of high risk patients in high dependency unit
Early Upper Gi endoscopy once stable
–Endotherapy
–Specific medications
Embolisation or surgery if not possible to control endoscopically
What are some additional medical treatments you can include in the management of someone with upper GI bleeding.
Adjuvant to endoscopy:
- Omeprazole
- Terlipressin +/- broad spectrum antibiotics (vatical bleed)
What are the high risk factors for UGI Bleed?
Factors showing severe event
Age >50 Co-morbidities (Liver, cardiac, respiratory) Inpatients Initial presentation with: -Haematemesis -Malaena -Shock -Collapse Continued bleeding after admission Elevated blood urea
What is the Rockall Score?
Pre-endoscopic risk assessment in UGIB
Simple and widely validated scoring system
Principally designed to predict death
May also be used to predict rebleeding risk
Based primarily off age, shock and co-morbidities
What is the Blatchford score?
Clinical information on admission:
-Hb, urea, Pulse, BP, Syncope, Malaena, Liver & HF
Predicts need for intervention more accurately than Rockall
Useful in deciding when not to do endoscopy
How do you manage a bleeding peptic ulcer?
RESUSCITATION Endoscopy Endotherapy PPI Check helicobacter pylori status Discontinue causative/ contributory medications
When should PPI like omeprazole be given?
Following endoscopic haemostats therapy
After 1 week eradication course for H. Pylori
Non-NSAID users: Discontinue PPI after successful healing of ulcer and H. Pylori eradication
NSAID, Aspirin or COX-2 users: Concomitant PPI therapy
What drugs should be discontinued or used with caution in patients with PU or UGIB?
Withhold:
-Oral anticoagulants, Aspirin, NSAIDs acutely
Use with caution:
- Selective Serotonin Reuptake Inhibitors
- A non SSRI antidepressant may be an appropriate choice in such patients
Oral anticoagulants or corticosteroids should be used with caution in patients at risk from GI bleeding, especially in those taking aspirin or NSAIDs
Why is everyone so hung up on resuscitation before endoscopy?
Optimum resuscitation is essential before endoscopy in order to reduce the potential cardio-respiratory complication of the procedure.
In acute upper GI bleeding when should you aim to get the endoscopy done?
Within 24 hours of the initial presentation where possible
What are the endotherapy options in acute UGIB?
Injection: adrenaline
Thermal: Contact or Non-Contact
Mechanical: Haemostatic clips, Band ligation
Combination: Injection + Thermal or Injection + Clips
What can you consider if you can’t stop an acute bleed endoscopically?
Angiography + embolisation
Laparotomy and resection of infected organ
-Partial gastrectomy
How do you deal with a variceal bleed endoscopically?
Oesophageal: Band ligation, Glue injection
Gastric: Glue injection
Rectal: Glue injection
Ideally intubated for airway protection
What additional management would you use in a variceal bleed?
IV Terlipressin
- Vasoconstrictor of splanchnic blood supply
- –Reduces blood flow to portal vein, reducing portal pressures
IV broad spectrum antibiotics
–often precipitated by systemic infection
Correct coagulopathy
How do you deal with an uncontrolled variceal bleed?
Sengstaken-Blakemore tube
- Tamponade to OG junction
- Temporary measure
TIPSS
-Transjugular intrahepatic port shunt
What should you do with individuals at high risk of re-bleeding?
TIPS early on
What are the major causes of lower GI bleeding?
Diverticular disease Vascular malformations (angiodysplasia) Haemorrhoids Neoplasia (carcinoma or polyps) Ischeamic colitis Radiation enteropathy/ proctitis IBD (e.g. ulcerative proctitis, Crohn's disease)
Give a description of diverticular disease from a GI bleed point of view
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
Diverticulosis = presence
Diverticulitis = Inflammation
Bleeding occurs in 10-20% during the lifetime
Usually self limiting (75%)
Risk of further bleeding
What is colonic angiodysplasia?
Vascular malformation (degeneration)
Friable and bleeds easily
May be association with valvular abnormalities
Bleeding often precipitated by anticoagulants/ anti-platelets
Can occur in small bowel also
Treatment with Argon Phototherapy
What is ischaemic colitis?
Disruption in blood supply to colon Presents with crampy abdominal pain More common in over 60 year olds Usually self limiting Complications include gangrene and perforation
If colonic causes are not found for bleeding and upper GU has been excluded, what’s next?
Need to consider small bowel origin
What are some small bowel bleeding causes?
Small bowel angiodysplasia Small bowel tumour/ GIST Meckel's diverticulum Small bowel ulceration Aortoentero fistulation - following AAA repair
How do you investigate (imaging) lower GI bleeding?
CT angiography
Formal angiography
Small bowel capsule enteroscopy
Double balloon enteroscopy
What are the blood investigations for lower GI bleeding?
Full blood count U+E LFT Coagulation Blood group and save x match
What is the management of lower GI bleeding?
Colonoscopic haemostatic techniques (adrenaline injections, bipolar coagulation , endoscopic haemoclipping)
Angiography and embolisation
Band ligation for haemorrhoids
Surgery:
-Segmental intestinal resection or subtotal colectomy
What are the risk factors for mortality in lower GI bleeding?
Age Co-morbidity Inpatients Initial shock Drugs : NSIADs and aspirin
Describe shock in acute GI bleeding
Shock = circulatory insufficiency resulting in inadequate oxygen delivery leading to global hypo perfusion and tissue hypoxia.
In GI bleeding the shock is most likely to be hypovolaemic
(aka haemorrhagic)
- Tachypnoea
- Tachycardia
- Anxiety or confusion
- Cool clammy skin
- Low urine output (oliguria)
- Hypotension
Patient with normal BP may still be in shock and require resuscitation
Where should you send patients who come in with acute UGIB?
Should be admitted, assessed and managed by a dedicated GI bleeding unit
