Acute GI Bleeding Flashcards
What effects the outcome of acute GI bleeding?
Identifications and prompt management
What is considered upper GI bleeding?
- Bleeding from the oesophagus, stomach or duodenum
- Proximal to ligament of Trietz
What is considered lower GI bleeding?
- Bleeding distal to duodenum (jejunum, ileum, colon)
- Distal to ligament Trietz
What can upper GI bleeding present as?
- Haematemesis
- Melaena
Why is urea elevated in upper GI bleeding?
Partially digested blood>haem>urea
What is upper GI bleeding associated with?
- Dyspepsia
- Reflux
- Epigastric pain
- NSAID use
What can lower GI bleeding present as?
- Fresh blood/clots
- Magenta stools
- Typically painless
When is lower GI bleeding more common?
In advanced age
What are the possible sites of upper GI bleeding?
- Oesophagus
- Stomach
- Duodenum
Where can ulcers occur?
All areas
When do ‘itis’ conditions tend to bleed?
Tend to bleed in context of abnormal clotting
What causes of upper GI bleeding can occur in the oesophagus?
- Oesophageal varices
- Mallory Weiss tear
- Oesophageal malignancy
What causes of upper GI bleeding can occur in the stomach?
- Gastric varices
- Gastric malignancy
- Dieulafoy
- Angiodysplasia
What cause of upper GI bleeding can occur in the duodenum?
Angiodysplasia
What is the most common cause of acute upper GI bleed?
Ulcer
What questions are useful in making a diagnosis for upper GI bleeding?
- Are you on any medications?
- Have you had any abdominal pain?
- Has there been any change in weight recently?
- What is your alcohol consumption per week?
- Do you take any painkillers?
What is the most common GI ulcer?
Duodenal
What are the risk factors for peptic ulcers?
- H pylori
- NSAIDs/aspirin
- Alcohol excess
- Systemic illness
Why is H pylori a risk factor for peptic ulcers?
- Urease production
- Ammonia production
- Buffers gastric acid
- Increased acid production
Why are NSAIDs and aspirin risk factors for peptic ulcers?
- Prostoglandin production
- Reduced mucus and bicarbonate excretion
- Reduced physical defences
What does Zollinger-Ellison syndrome cause?
Recurrent poor healing duodenal ulcers
What may gastric ulcers sit over?
- Gastric carcinoma
- Repeat endoscopy indicated at 8 weeks
What impaired coagulation could lead to bleeding of gastritis and duodenitis?
- Medical conditions
- Anti-coagulants
- Anti-platelets
When are you more likely to have significant bleeding with oesophagitis?
If on anti-platelets or anti-coagulation
What can cause oesophagitis?
- Reflux
- Hiatus hernia
- Alcohol
- Bisphosphonates
- Systemic illness
What are varices secondary to?
Portal hypertension usually due to liver cirrhosis
Varices
Abnormally dilated collateral vessels
What is the incidence of varices within the GIT?
- Oesophageal 90%
- Gastric 8%
- Rectal and splenic rare
What can lead to life threatening bleeding with varices?
Increases in portal pressure (due to infection, drug us etc)
What is there usually a history of with oesophageal cancer?
- Dysphagia
- Weight loss
What is the typical character of bleeding due to oesophageal cancer?
Typically ooze
What other manifestation can gastric cancer present as?
Ulcer
What does GU require for healing?
Interval endoscopy for healing
What is a Mallory-Weiss tear?
Linear tear at oesophageal-gastric junction
What does a Mallory-Weiss tear usually follow?
Period of retching/vomiting
What is the outcome of a Mallory Weiss tear?
Up to 10% require endoscopic treatment
-Most heal on their own
Diuelafoy
Submucosal arteriolar vessel eroding through mucosa
Where do diuelafoy occur?
Gastric fundus
What is angiodysplasia?
Vascular malformation
Where can angiodysplasia occur?
Anywhere in the GIT
What is angiodysplasia a frequent cause of?
Chronic occult or overt occult bleeding
What is angiodysplasia associated with?
Chronic conditions including heart valve replacement
What are colonic cause of lower GI bleeding?
- Diverticular disease
- Haemorrhoids
- Vascular malformations
- Neoplasia
- Ischaemic colitis
- Radiation enteropathy/proctitis
- Inflammatory bowel disease
What does the diagnosis of cause of lower GI bleeding require?
Flexible sigmoidoscopy or full colonoscopy
Diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
Diverticulosis
Presence of diverticular disease
Diverticulitis
Inflammation in diverticular disease
What is there a risk of with lower GI bleeding due to diverticular disease?
Further bleeding
What is the prognosis of bleeding due to diverticular disease?
Usually self limiting
Haemorrhoids
Enlarged vascular cushions around anal canal
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 may angiodysplasia be associated with?
Valvular abnormalities
What is bleeding due to angiodysplasia often precipitated by?
Anticoagulants/antiplatelets
What is the treatment for angiodysplasia?
Argon Phototherapy
What is included in colonic neoplasia?
Colonic polyps or carcinoma
Ischaemic colitis
Disruption in bloody supply to colon
What does ischaemic colitis affect areas according to?
Blood supply
What does ischaemic colitis present with?
Crampy abdominal pain
When is ischaemic colitis more commen?
Over 60 years of age
What is usually the outcome of bleeding due to ischaemic colitis?
Self limiting
What complications are associated with ischaemic colitis?
- Gangrene
- Perforation
What is the appearance of ischaemic colitis?
Dusky blue swollen mucosa
What is there a history of in radiation proctitis?
Previous history of radiotherapy especially for cervical/prostate cancer
What be people with radiation proctitis be dependent on?
Blood transfusions due to chronic loss
What is the treatment for radiation proctitis?
- APC
- Sulcrafate enemas
- Hyperbaric oxygen
What is included in the umbrella term IBD?
- UC
- CD
What does treatment of IBD depend on?
Extent/severity
If there is no colonic cause of lower GI bleeding and upper GI bleeding has been excluded what should be considered?
Small bowel origin
What small bowel origins of bleeding is there?
- Meckels diverticulum
- Small bowel angiodysplasia
- Small bowel tumour/GIST
- Small bowel ulceration (NSAID associated)
- Aortoentero fistula
What small bowel investigations are there for bleeding?
- CT angiogram
- Meckels scan (scintigraphy)
- Capsule endoscopy
- Double balloon enteroscopy
What is the diagnostic investigation for Meckel’s diverticulum?
Nuclear scintigraphy
Meckel’s diverticulum
Gastric reminant mucosa
What protocol should be followed for GI bleeding?
Major haemorrhage protocol
What approach should be used for resuscitation for GI bleeding?
ABCDE
How should circulation be dealt with immediately?
- Wide bored IV access
- Iv fluids
- Blood transfusion (if Hb <7g/dl or ongoing bleeding)
- Urgent bloods
Once resuscitated, what else is involved in the management of acute GI bleeding?
- Risk stratification for placement in HDU
- Endoscopy once stable
- Withhold/reverse contributory medications
- Specific medications
- Consider CT angiography/interventional radiology/surgical interventions as appropriate
Shock
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypo perfusion and tissue hypoxia
What are the signs of haemorrhagic shock?
- Tachypnoea
- Tachycardia
- Anxiety or confusion
- Cool clammy skin
- Ogliuria
- Hypotension
How can shock be classified?
4 stages according to total blood loss
What is the Blatchford score used for?
Decide who requires endoscopy
What does the Rockall score predict?
Principally used to predict death but can also be used to predict rebleed
What is the link with age and lower GI bleeding?
-Often in the elderly
What is the link between co-morbidities an lower GI bleeding?
Presence of 2 co-morbid conditions doubles the chances of severe bleed
What is the management for peptic ulcers?
- Proton pump inhibitor
- Endoscopy with endotherapy
- Angiography with embolization
- Laparotomy
What endoscopic therapy options are there for peptic ulcers?
- Injection
- Thermal
- Mechanical
- Haemospray
- Combination
If a peptic ulcer bleeds uncontrollably endoscopically what should be done?
- Angiography and embolization
- Laparotomy
What options are there for endotherapy for varices?
Endotherapy
- Oesophageal (band ligation/ glue injection)
- Gastric (glue injection)
- Rectal (glue injection)
What should the patient ideally be when undergoing endotherapy for varices?
Intubated for airway protection
What is involved in the management of varices?
- Endotherapy
- IV terlipressin (vasoconstrictor of splanchnic blood supply)
- Iv broad spectrum antibiotics
- Correct coagulopathy
What options are there when bleeding is uncontrollable at endoscopy of varices?
- Sengstaken-Blakemore tube
- Transjugular intrahepatic porto-systemic shunt
