Acute GI bleeding Flashcards
What structure separates the lower and upper GI tract?
ligament of trietz - between duodenum and jejunum
What are some symptoms which point more to being an upper GI problem?
haematemesis and melaena
elevated urea due to partially digested blood
dyspepsia, reflux, epigastric pain
NSAID use eg ibuprofen
What are some symptoms which point more to being a lower GI problem?
fresh blood per rectum magenta stools painless older patients normal urea
Name as many causes of upper GI bleeding as you can
ulcers and inflammation
oesophagus - varices, GORD, Mallory Weiss tear, malignancy
stomach - diuelafoy, angiodysplasia - also in duodenum
What are some causes of oesophagitis?
bisphosphonates use reflux osteoporosis hiatus hernia alcohol
What causes oesophageal varices?
portal hypertension due to liver failure
How may oesophageal and gastric cancer present differently?
gastric - as an ulcer
oesophageal - dysphagia, reflux, ooze
What is a Mallory Weiss tear and how is it treated?
tear at gastro-oesophageal junction after a period of retching and vomiting and requires endoscopic treatment
What are diuelafoy?
abnormal blood vessel usually found in the gastric fundus which erode from the submucosa to mucosa and bleed
What is angiodysplasia?
abnormal vascular formation in the GI tract linked to heart valve replacement which cause chronic bleeding
Describe briefly some important findings on a history taking for peptic ulcer
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
What are the main risk factors for peptic ulcers and why?
H pylori -> urease -> ammonia -> buffers gastric acid -> increase acid production
alcohol excess
NSAIDS/aspirin -> prostaglandin reduces mucus and defences
systemic illness -> stress ulcer
Why must endoscopy be repeated in 8 weeks for a gastric ulcer?
may sit over a gastric carcinoma
What is zollinger-ellison syndrome and what investigation must be carried out if this is suspected?
pancreatic tumour secreting gastrin causing recurrent bleeding of gastric ulcers
look at pancreas for tumours
When do gastritis and duodenitis tend to bleed?
impaired coagulation eg medical condiions, medication eg antiplatelets, anticoagulants
List some colonic causes of lower GI bleeding
neoplasia - cancer, polyps
diverticular disease, IBD, ischaemic colitis, radiation proctitis, haemorrhoids, vascular malformation
How are lower GI bleeding causes diagnosed?
flexible sigmoidoscopy or full colonoscopy
What is diverticular disease?
protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
What is diverticulosis and diverticulitis?
presence
inflammation
How is diverticular disease treated?
usually self limiting
What are haemorrhoids and what 2 reasons will they be painful?
enlarged vascular cushions around the anal canal
thrombosed or external
What are haemorrhoids associated with?
low fibre diet, straining and constipation
What is ischaemic colitis and how does it present?
disruption in blood supply to the colon
blue swollen mucosa, gangrene, perforation
in over 60s, self limiting and crampy abdominal pain
What is radiation colitis related to?
radiotherapy for prostate and cervical cancer
What are some small bowel causes of GI bleeding?
meckels diverticulum, small bowel tumour, angiodysplasia, ulcer, aortoentero fistula on AAA repair
What is meckels diverticulum?
gastric mucosa remnant present in 2% population found 2ft from ileocaecal valve and 2 inches long
How is Meckels diverticulum diagnosed?
scinitgraphy
Name 4 investigations used for the small bowel
meckels scan - scintigraphy
CT angiogram
capsule endoscopy and double balloon enteroscopy with biopsy
What is the management of GI severe bleeding?
ABCDE approach
IV fluids, blood transfusion hb <7g/dl, blood samples, catheter
once stable endoscopy, medication etc
What is shock?
circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
What are symptoms of the haemorrhagic subtype of shock?
tachypnoea, tachycardia, cold clammy skin, confusion, low blood pressure, low urine output
What are the 2 scores used for upper GI bleeding?
Rockall - death/rebleeding
Blatchford - endoscopy, who needed it
What is taken into account for lower GI bleeding as there are no definite scoring systems
age, co-morbidities, inpatient, initial shock, drugs
Name the 4 managements of peptic ulcers
PPI, endoscopy with endotherapy, laparotomy, angiography with embolization
Why are endoscopies and endotherapies used in GI bleeding and what endotherapies are possible?
to identify risk of bleeding
thermal, injection, mechanical clip
When are laparotomy and angiography with embolization used in peptic ulcer management?
when bleeding is uncontrollable with endoscopy
What endotherapy can be used on varices
oesophageal - band ligation
Oesophageal, gastric, rectal - glue injection
Other treatment for varices
IV vasoconstrictor, broad spectrum antibiotics, correct coagulopathy
