Acute GI bleeding Flashcards
What bleeding is classed as upper GI?
Oesophagus
Stomach
Duodenum
What are the clinical manifestations of upper GI bleeding?
Haemetemesis Melaena Elevated urea Dyspepsia, reflux, epigastric pain NSAIDs use
What are the causes of upper GI bleeding?
Ulcers Inflammation Varices Angiodysplasia Malignancy Tear
What are the most common ulcers in the GI tract?
Duodenal
What are the risk factors for ulcers?
H. pylori
NSAIDs
Alcohol excess
Systemic illness
What may gastric ulcers cover?
Gastric carcinoma
What is Zollinger-Ellison syndrome and what does it cause?
Gastrin secreting pancreatic tumour
Causes recurrent poorly healing duodenal ulcers
When does inflammation tend to bleed?
In context of impaired coagulation e.g. medical conditions, anticoagulants, anti platelets
What is oesoophagitis?
Inflammation of oesophagus
What are the causes of oesophagi’s?
Reflux Hiatus hernia Alcohol Bisphosphonates Systemic illness
When are you more likely to get significant bleeding from inflammation?
If patient is on anticoagulants or antiplatelets
What are varices?
Abnormally dilated tortuous collateral vessels
What are varices secondary to?
Portal hypertension and usually cirrhosis
What is the main site of varices?
Oesophagus
What can cause varices to bleed?
Increased portal pressure
What is angiodysplasia?
Vascular malformation
Where can angiodysplasia occur?
Anywhere in GI tract
Where does lower GI bleeding occur?
Distal to duodenum (ligament of Trietz)
What are the clinical manifestations of lower GI bleeding?
Fresh blood/clots Magenta stools Normal urea Typically painless More common in advanced age
What are the colonic causes of lower GI bleeding?
Diverticular disease Haemorrhoids Angiodysplasia Neoplasia Ischaemic colitis Radiation enterotherapy/procitis IBD
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscle layer, forming a pouch
What is diverticulitis?
Inflammation of diverticular pouch
What are haemorrhoids?
Enlarged vascular cushions around anal canal
What are haemorrhoids associated with?
Straining
Constipation
Low fibre diet
When are haemorrhoids painful?
If thromboses or external
What causes angiodysplasia in the lower GI tract?
Degeneration
What are the features of lower GI angiodysplasia?
Friable, bleeds easily
Associated with valvular abnormalities
What is bleeding in angiodysplasia often preceded by?
Use of anticoagulants and antiplatelets
What is the treatment of lower GI angiodysplasia?
Argon phototherapy
What does ischaemic colitis present with?
Crampy abdo pain
Diarrhoea with blood
Over 60s
Where does ischaemic colitis often affect?
Descending sigmoid colon
What does ischaemic colitis affect areas according to?
Associated blood supply
What are the complications of Ischaemic colitis?
Gangrene
Perforation
What is the appearance of the mucosa in ischaemic colitis?
Dusky blue, almost bruised looking mucosa
What does radiation enterotherapy cause?
Cresendo PR bleeding which may cause the patient to be blood transfusion dependent
What is the treatment of radiation enteropathy?
APC
Sulfcrafate enemas
Hyperbaric oxygen
What is radiation enteropathy dependent on a history of?
Previous radiotherapy on cervix or prostate
What is the presentation of bleeding with IBD?
Slower onset with diarrhoea symptoms
What is treatment of bleeding in IBD dependent on?
Extent and severity
What are the small intestine causes of lower GI bleeding?
Meckel’s diverticulum
Small bowel angiodysplasia/tumour/ulceration
Aortoentero fistulation
What is Meckel’s diverticulum?
Gastric remnant mucosa 2 feet from ileocaecal valve
What is small bowel ulceration associated with?
NSAIDs
What is aortoentero fistulation associated with?
AAA repair
What is the major haemorrhage protocol?
IV fluids Blood transfusion (Hb <7) Urgent bloods to lab (FBC, U+E, LFT, coagulation) Catheter Risk calculation for placement in HDU Endoscopy once stable
How is GI bleeding managed?
Blood transfusion if Hb <7
Review medications
Consider CT angiography/interventional radiology/surgical intervention
How are peptic ulcers treated?
Proton pump inhibitors
Endoscopy with end-therapy- injection of adrenaline
thermal
clip
haemospray
combination (usually adrenaline + thermal/clip)
How is uncontrollable bleeding from a peptic ulcer treated?
Angiography with embolisation
Laparotomy
How are varices treated?
Endotherapy
IV terlipression and bro spectrum antibiotics
Coagulotherapy
Intubate to secure airway
How are oesophageal varices treated?
Band ligation
Glue injection
How are gastric and rectal varices treated?
Glue injection
How in uncontrollable bleeding from varices treated?
Transjugular intrahepatic portosystemic shunt
What is shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to hypo perfusion and hypoxia
What are the clinical features of shock?
Tachycardia Tachypnoea Anxiety/confusion Cool, clammy skin Oliguria Hypotension
What do risk stratification scores in shock do?
Allow for assessment of management/admission etc
