Acute GI Bleeding Flashcards
What are the symptoms of upper GI bleed / important in the hX
Haematemesis - bright red or coffee Epigastric pain Melaena - black motions (often foul / loose) Increased urea as haem broken down out of proportion to creatinine Anaemia Signs of shock / syncope Dyspepsia Reflux Tachy / ill before bleed Weakness
History of
- Past GI bleed
- Ulcers
- Liver disease or varices
- Drugs - NSAID
What causes upper GI
Oesophageal / gastric varices
Peptic / duodenal ulcer = most common
Mallory Weiss tear - self limiting after retching or vomit - 2nd most common
Malignancy
Gastritis / oesophagitis
Drugs - NSAID / SSRI / steroid / anti-coagulant
Rare Aorta-enteric fistula after AAA repair Bleeding disorder Dieuloafoy lesion - large torturous arteriole Angiodysplasia Meckel's
What should you enquire about
Dyspepsia Dysphagia Reflux Signs of shock NSAID / drug Hx Past Hx of bleed / ulcers / GI bleed / varicose / alcohol
What puts you at increase risk of bleed
Age >60 Co-morid Inpatient NSAID Anti-coagulant Liver disease
What is predictor of severity
Initial shock
What imaging and tests in acute setting
CXR / AXR
ECG
ABG
Do PR to look for maelana
What anaemia is suggestive of bleed
Iron
DO ENDOSCOPY
What other imaging
Balloon / MR enteroscopy - small bowel
CT angiogram
Meckelscan
CT CAP
What score is used for initial assessment
Blatchford - assess whether another bleed is likely and when endoscopy is needed
What score suggest admission / endoscopy
> 6
What does blatchford score take in
Sex Urea - rises as breakdown product which is absorbed into the intestines Hb BP Hepatic / cardiac failure Tachycardia Malaena Syncope
What score is used after endoscopy to monitor risk of rebelled / predict mortality
Rockall
What does Rockall look at
Age Pulse BP CVP Urine FBC, U+E, LFT, clotting Co-morbid Cause of bleed
How do you manage all upper G bleed
A - protect airway (can suction vomit)
B - 15l O2 NRB
C - IV access with 2 wide bore cannula, fluid, blood, FBC, U+E, LFT, cross-match, coag, transfusion if needed, VBG, regular BP monitor
D - catheter / fluid restrict
E - NBM / correct clotting / stop anti-coagulant / ECG / keep warm
When do you transfuse
Transfuse, blood, platelets and FFP if massive haemorrhage
Hb <70
Platelet <100 if major or 30 if minor
FFP if fibrongn <1 or PT > 1.5
Prothromin complex can be given to reverse warfarin
How do you monitor and what bloods
BP, Pulse, CVP
G+S or X-match
FBC, U+E, LFT, lipase
VBG
Clotting and INR
What do you do when stable
Endoscopy if Blatchford >6
Immediate if severe or variceal bleed
Or within 24 hours of admission for other
Consider angiography / surgery if endoscopy fails to control / already been done 2x
What do you give to reduce risk of further bleed
IV BB
How do you treat varices
ABCDE as above
- Get clotting + FBC as probably deranged due to liver function and correct
If patient unstable = give O-ve blood as fluid will just dilute
Terlipressin + Iv Ax prior to endoscopy (Quinolone)
- Terlipressin = stabilises patient
Emergeny endoscopy within 4 hours
- If during the night will need to call someone in
- Band litigation or glue during endoscopy
Balloon tamponade if can’t get someone to do endoscopy + uncontrollable bleed
Sengansten Blackmore tube if all else fails
TIPS if that fails
What do you give after endoscopy as prophylaxis
BB
Band ligation and PPI continuous infusion until eradicated
How do you treat angiodysplasia
Colonosocpy to Dx
Argon phototherapy
Anti-fibinrolytic
What does terlipressin do
Vasoconstriction of splanchnic blood supply
Reduce portal tension
What bloods in rectal bleed
QFIT FBC, U+E, LFT, ferritin Coeliac CRP Calprotectin DRE
Signs of shock
High RR / HR Low BP Low urine output Anxiety Confusion Decreased GCS Prolonged cap refil Cool clammy skin
What are more common causes of rectal bleed
Diverticulitis Malignancy - colorectal cancer Haemorrhoids IBD Perianal disease Angiodysplasia Gastroenteritis
What are rare causes
Trauma Ischameic colitis Radiation proctitis Aorta enteric fistula following AAA repair Meckels
What are symptoms of lower GI bleed
Fresh blood clot Magenta stool Normal urea Anaemia Painless
How do you investigate lower GI bleed
DRE
Colonoscopy
Bloods
Angiogram if patient unstable to identify bleeding
What bloods
FBC, U+E, LFT, Ca, TFT Clotting Amylase CRP Group and save Stool MC+S Coeliac Calprotectin QFIB
What imaging
AXR if sign of sepsis / peritonitis
How do you manage lower GI bleed
ABCDE Insert 2 cannula Catheter Crystalloid replacemnt Blood transfusion Ax if sepsis / perforation Start a stool chart Angiography+ embolization CT angiography = non invasiv Colonscopy Surgery if massive
Can you put bleeding down to haemorrhoids
Not without internal inspection as can be impalpable
What artery affected
Gastroduodenal
When should you consider admission
> 60
Co-mornid
Unstable
Aspirin / NSAID use
Why do you do U+E
Colonoscopy require lots of laxatives before
Why is ferritin useful
Drops before Hb
What is TIPS
Connection between inflow portal vein and outflow hepatic vein
Used to reduce portal HTN
