Acute GI bleeding

Question 1

What structure separates the lower and upper GI tract?

Answer 1

ligament of trietz - between duodenum and jejunum

Question 2

What are some symptoms which point more to being an upper GI problem?

Answer 2

haematemesis and melaena
elevated urea due to partially digested blood
dyspepsia, reflux, epigastric pain
NSAID use eg ibuprofen

Question 3

What are some symptoms which point more to being a lower GI problem?

Answer 3

fresh blood per rectum 
magenta stools 
painless
older patients
normal urea

Question 4

Name as many causes of upper GI bleeding as you can

Answer 4

ulcers and inflammation
oesophagus - varices, GORD, Mallory Weiss tear, malignancy
stomach - diuelafoy, angiodysplasia - also in duodenum

Question 5

What are some causes of oesophagitis?

Answer 5

bisphosphonates use 
reflux 
osteoporosis
hiatus hernia 
alcohol

Question 6

What causes oesophageal varices?

Answer 6

portal hypertension due to liver failure

Question 7

How may oesophageal and gastric cancer present differently?

Answer 7

gastric - as an ulcer

oesophageal - dysphagia, reflux, ooze

Question 8

What is a Mallory Weiss tear and how is it treated?

Answer 8

tear at gastro-oesophageal junction after a period of retching and vomiting and requires endoscopic treatment

Question 9

What are diuelafoy?

Answer 9

abnormal blood vessel usually found in the gastric fundus which erode from the submucosa to mucosa and bleed

Question 10

What is angiodysplasia?

Answer 10

abnormal vascular formation in the GI tract linked to heart valve replacement which cause chronic bleeding

Question 11

Describe briefly some important findings on a history taking for peptic ulcer

Answer 11

HPC: dyspepsia, weight loss, collapse, poor urine output, melaena/haematemesis
PMH: liver disease, co-morbidities
DH: NSAIDS, steroids, anticoagulants, antiplatelets
SH: alcohol, smoking
FH: H pylori, peptic ulcers

Question 12

What are the main risk factors for peptic ulcers and why?

Answer 12

H pylori -> urease -> ammonia -> buffers gastric acid -> increase acid production
alcohol excess
NSAIDS/aspirin -> prostaglandin reduces mucus and defences
systemic illness -> stress ulcer

Question 13

Why must endoscopy be repeated in 8 weeks for a gastric ulcer?

Answer 13

may sit over a gastric carcinoma

Question 14

What is zollinger-ellison syndrome and what investigation must be carried out if this is suspected?

Answer 14

pancreatic tumour secreting gastrin causing recurrent bleeding of gastric ulcers
look at pancreas for tumours

Question 15

When do gastritis and duodenitis tend to bleed?

Answer 15

impaired coagulation eg medical condiions, medication eg antiplatelets, anticoagulants

Question 16

List some colonic causes of lower GI bleeding

Answer 16

neoplasia - cancer, polyps

diverticular disease, IBD, ischaemic colitis, radiation proctitis, haemorrhoids, vascular malformation

Question 17

How are lower GI bleeding causes diagnosed?

Answer 17

flexible sigmoidoscopy or full colonoscopy

Question 18

What is diverticular disease?

Answer 18

protrusion of the inner mucosal lining through the outer muscular layer forming a pouch

Question 19

What is diverticulosis and diverticulitis?

Answer 19

presence

inflammation

Question 20

How is diverticular disease treated?

Answer 20

usually self limiting

Question 21

What are haemorrhoids and what 2 reasons will they be painful?

Answer 21

enlarged vascular cushions around the anal canal

thrombosed or external

Question 22

What are haemorrhoids associated with?

Answer 22

low fibre diet, straining and constipation

Question 23

What is ischaemic colitis and how does it present?

Answer 23

disruption in blood supply to the colon
blue swollen mucosa, gangrene, perforation
in over 60s, self limiting and crampy abdominal pain

Question 24

What is radiation colitis related to?

Answer 24

radiotherapy for prostate and cervical cancer

Question 25

What are some small bowel causes of GI bleeding?

Answer 25

meckels diverticulum, small bowel tumour, angiodysplasia, ulcer, aortoentero fistula on AAA repair

Question 26

What is meckels diverticulum?

Answer 26

gastric mucosa remnant present in 2% population found 2ft from ileocaecal valve and 2 inches long

Question 27

How is Meckels diverticulum diagnosed?

Answer 27

scinitgraphy

Question 28

Name 4 investigations used for the small bowel

Answer 28

meckels scan - scintigraphy
CT angiogram
capsule endoscopy and double balloon enteroscopy with biopsy

Question 29

What is the management of GI severe bleeding?

Answer 29

ABCDE approach
IV fluids, blood transfusion hb <7g/dl, blood samples, catheter
once stable endoscopy, medication etc

Question 30

What is shock?

Answer 30

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

Question 31

What are symptoms of the haemorrhagic subtype of shock?

Answer 31

tachypnoea, tachycardia, cold clammy skin, confusion, low blood pressure, low urine output

Question 32

What are the 2 scores used for upper GI bleeding?

Answer 32

Rockall - death/rebleeding

Blatchford - endoscopy, who needed it

Question 33

What is taken into account for lower GI bleeding as there are no definite scoring systems

Answer 33

age, co-morbidities, inpatient, initial shock, drugs

Question 34

Name the 4 managements of peptic ulcers

Answer 34

PPI, endoscopy with endotherapy, laparotomy, angiography with embolization

Question 35

Why are endoscopies and endotherapies used in GI bleeding and what endotherapies are possible?

Answer 35

to identify risk of bleeding

thermal, injection, mechanical clip

Question 36

When are laparotomy and angiography with embolization used in peptic ulcer management?

Answer 36

when bleeding is uncontrollable with endoscopy

Question 37

What endotherapy can be used on varices

Answer 37

oesophageal - band ligation

Oesophageal, gastric, rectal - glue injection

Question 38

Other treatment for varices

Answer 38

IV vasoconstrictor, broad spectrum antibiotics, correct coagulopathy