Acute GI Bleeding Flashcards
How is Upper GI bleeding defined?
Oesophagus, stomach or duodenum
Proximal to ligament of Treitz
How is Lower GI bleeding defined?
Distal to duodenum
Distal to ligament of Treitz
Presentation of Upper GI bleed
Haematemesis
Melaena
Elevated Urea
Dyspepsia, reflux symptoms
What is upper GI bleed associated with?
NSAID use
How does lower GI bleed present?
Fresh blood/clots Magenta stools Normal urea Painless Common in advanced age
Urea is raised in what GI bleed? Why?
Upper
Digested blood Haem -> Urea
Causes of upper GI bleed
Ulcers
-itises
Varices/Malignancy oes/stom
Angiodysplasia
What is angiodysplasia?
Small vascular malformation in the GI system
What are the 3 most common causes of upper GI bleeds?
Peptic ulcer
Gastritis
Oesophagitis
Which is the most common peptic ulcer?
Duodenal
What are the risk factors for peptic ulcers?
H. pylori
NSAIDS/aspirin
Excess alcohol
Systemic illness
How do NSAIDS/aspirin cause peptic ulcers?
Decreased prostaglandin production
Reduced mucus, bicarb production
Reduced defences
What must be taken into consideration when you find a peptic ulcer?
Ulcer may sit over a carcinoma - repeat endoscopy at 8 weeks
Zollinger-Ellison syndrome
What is Zollinger Ellison syndrome?
Recurrent poorly healing duodenal ulcers
What are the risk factors for gastritis/duodenitis?
Excess alcohol
NSAIDS/Aspirin
H. pylori
Systemic illness
When are gastritis/duodenitis at increased risk of bleed?
When patient has
impaired coagulation
What increases the risk of impaired coagulation?
Illness
Anticoagulants
Anti-platelets
When is oesophagitis at increased risk of bleeding?
When the patient has impaired coagulation
What are the main causes of oesophagitis?
Reflux Hiatus hernia Alcohol Bisphosphonates Systemic illness
How can Liver cirrhosis cause a left upper quadrant mass?
Splenomegaly secondary to portal hypertension
What are varices?
Increased portal pressure causing dilated anastamoses
What is a Mallory-Weiss tear?
Linear tear at gastro-oesophageal junction
When does a Mallory-Weiss tear commonly occur?
Periods of retching/vomiting
What is a Diuelafoy lesion?
A submucosal arteriolar vessel eroding through the mucosa
Where does a Diuelafoy most commonly occur?
Gastric fundus
Where can angiodysplasia occur?
Anywhere in the GI tract
Angiodysplasia is a frequent cause of what?
Occult blood
What is occult blood?
Blood in the stool which isnt visibly apparent
Angiodysplasia is associated which what?
Chronic conditions
Valve replacement
What investigations would you perform on a patient with a Upper GI bleed?
UGIE
diagnostic and therapeutic
What are the colonic causes of Lower GI bleed?
Diverticular disease Haemorrhoids Angiodysplasia Neoplasia Ischaemia Radiaton enteropathy IBD
What is essential in diagnosis for Lower GI bleed?
Full colonoscopy/flexible sigmoidoscopy
What is diverticulosis?
Presence of diverticuli
What is diverticulitis?
Inflammation of diverticuli
What are diverticuli?
Protrusion of the inner mucosal lining through the outer muscularis
What are haemorrhoids?
Enlarged muscular cushions around the anal canal
When are haemorrhoids painful?
If thrombosed or external
What are haemorrhoids associated with?
Straining
Constipation
Low fibre diet
Angiodysplasia is sometimes associated with what?
Heart valve abnormalities
Bleeding in angiodysplasia is associated with what?
Antiplatelets
Anticoagulants
Treatment for angiodysplasia
Argon phototherapy
Tranexamic acid
Thalidomide
What are the main types of colonic neoplasia?
Polyps
Carcinoma
What is ischaemic colitis?
Disruption of blood supply to the colon
How does ischaemic colitis present?
Crampy abdominal pain
Sudden bleeding
What visible changes occur on endoscopy in ischaemic colitis?
Dusky blue, swollen mucosa
What are the most common complications of ischaemic colitis?
Gangrene
Perforation
What treatment commonly occurs to cause radiation proctitis?
Cervical/prostate cancer radiotherapy
How does radiation proctitis present?
Crescendo rectal bleeding over months/years
Dependent on blood transfusions due to chronic loss
What is the treatment for radiation proctitis?
Argon Plasma Coagulation (APC)
Sulcrafate enemas
Hyperbaric oxygen
What are the recommended investigations for acute lower GI bleed?
Lower GI endoscopy
CT Angiography
If a patient presents with acute lower GI bleed, and no colonic cause is found, what must be excluded?
Upper GI bleed
Small bowel origin of LGI bleed
What are the most common causes of small bowel Lower GI bleed?
Meckel's Diverticulum SI Angiodysplasia SI tumour/GIST SI ulceration Aortoentero fistulation
What does an aortoentero fistulation commonly follow?
AAA repair
What small bowel investigations would be performed on a patient with acute Lower GI bleed?
CT Angiogram
Meckle’s scan
Capsule endoscopy
Double baloon enteroscopy
What is Meckel’s diverticulum?
Gastric remnant mucosa of the vitelline duct
How is Meckel’s diverticulum diagnosed?
Nuclear Scintigraphy
Where does Meckel’s diverticulum form in the body?
2ft from the ileocaecal valve
How is acute GI bleed managed?
ABCDE
Endoscopy within 24hrs
Reverse/stop contributary meds
Blood products?
What is shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion –> tissue hypoxia
How do you recognise haemorrhagic shock?
Tachypnoea Tachycardia Anxiety/confusion Clammy skin Oliguria Hypotension
How is shock classified?
Stages 1-4
How is stage 1 shock classified?
<15% blood loss
RR<20
HR<100
Normal urine
How is stage 2 shock classified?
15-30% blood loss RR 20-30 HR 100-120 Decreased pulse pressure Reduced urine output
How is stage 3 shock classified?
30-40% blood loss RR 30-40 HR 120-140 Low BP Low pulse pressure Confusion Very low urine output
How is stage 4 shock classified?
>40% blood loss RR >40 HR >140 Low BP Low Pulse pressure Confused/drowsy No urine output
How is risk in Upper GI bleed classified?
Rockall score
What does the Rockall score classify?
Risk of re-bleed
Risk of death
How is the need for endoscopy in Upper GI bleed classified?
(Blatchford score) Urea Hb BP Heart/liver disease
What other factors increase the risk to a patient with Lower GI bleed?
Age Co-morbidity Inpatients Shock/frank bleeding Drugs (NSAIDs, Aspirin)
How are bleeds caused by peptic ulcer managed?
PPIs
Endoscopy + endotherapy
Angiography with embolization
Laparotomy
What is the purpose of endoscopy for UGI bleeding caused by peptic ulcer?
Identify risk of further bleed
Look for cancers
Endoscopic therapy
What are the endoscopic therapy options for peptic ulcer?
Injection (adrenaline) Thermal (gold probe) Mechanical (clip) Haemospray Combination therapy
If a peptic ulcer cannot be controlled endoscopically, what is the next line of treatment?
Angiography + embolisation
Laparotamy
What are the management options for upper GI bleeds caused by varices?
Endotherapy: Glue injection, band ligation
IV Terlipressin
IV Broad spec. antiB
What is the role of IV Terlipressin?
Vasoconstrictor of splanchnic blood supply
(reduces blood flow to the
What treatment is indicated in varices bleeding, not controlled at UGIE?
Sengstaken-Blakemore tube
+
Transjugular intrahepatic porto-systemic shunt
What is coffee ground vomit?
Brown vomit, not always GI bleed, often systemic illness
Magenta stools suggest what?
Bleeding from right colon or distal ileum
What is haematochezia?
Passage of fresh/altered blood PR
Upper GI “fast transit” or lower GI
