Acute GI Bleeding Flashcards

1
Q

What are the symptoms of upper GI bleed / important in the hX

A
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
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2
Q

What causes upper GI

A

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
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3
Q

What should you enquire about

A
Dyspepsia
Dysphagia
Reflux
Signs of shock
NSAID / drug Hx
Past Hx of bleed / ulcers / GI bleed / varicose / alcohol
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4
Q

What puts you at increase risk of bleed

A
Age >60 
Co-morid
Inpatient
NSAID
Anti-coagulant 
Liver disease
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5
Q

What is predictor of severity

A

Initial shock

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6
Q

What imaging and tests in acute setting

A

CXR / AXR
ECG
ABG
Do PR to look for maelana

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7
Q

What anaemia is suggestive of bleed

A

Iron

DO ENDOSCOPY

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8
Q

What other imaging

A

Balloon / MR enteroscopy - small bowel
CT angiogram
Meckelscan
CT CAP

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9
Q

What score is used for initial assessment

A

Blatchford - assess whether another bleed is likely and when endoscopy is needed

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10
Q

What score suggest admission / endoscopy

A

> 6

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11
Q

What does blatchford score take in

A
Sex
Urea - rises as breakdown product which is absorbed into the intestines 
Hb
BP
Hepatic / cardiac failure
Tachycardia
Malaena
Syncope
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12
Q

What score is used after endoscopy to monitor risk of rebelled / predict mortality

A

Rockall

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13
Q

What does Rockall look at

A
Age 
Pulse
BP
CVP
Urine
FBC, U+E, LFT, clotting
Co-morbid
Cause of bleed
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14
Q

How do you manage all upper G bleed

A

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

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15
Q

When do you transfuse

A

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

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16
Q

How do you monitor and what bloods

A

BP, Pulse, CVP

G+S or X-match
FBC, U+E, LFT, lipase
VBG
Clotting and INR

17
Q

What do you do when stable

A

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

18
Q

What do you give to reduce risk of further bleed

19
Q

How do you treat varices

A

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

20
Q

What do you give after endoscopy as prophylaxis

A

BB

Band ligation and PPI continuous infusion until eradicated

21
Q

How do you treat angiodysplasia

A

Colonosocpy to Dx
Argon phototherapy
Anti-fibinrolytic

22
Q

What does terlipressin do

A

Vasoconstriction of splanchnic blood supply

Reduce portal tension

23
Q

What bloods in rectal bleed

A
QFIT
FBC, U+E, LFT, ferritin 
Coeliac
CRP
Calprotectin
DRE
24
Q

Signs of shock

A
High RR / HR
Low BP
Low urine output
Anxiety
Confusion
Decreased GCS
Prolonged cap refil
Cool clammy skin
25
What are more common causes of rectal bleed
``` Diverticulitis Malignancy - colorectal cancer Haemorrhoids IBD Perianal disease Angiodysplasia Gastroenteritis ```
26
What are rare causes
``` Trauma Ischameic colitis Radiation proctitis Aorta enteric fistula following AAA repair Meckels ```
27
What are symptoms of lower GI bleed
``` Fresh blood clot Magenta stool Normal urea Anaemia Painless ```
28
How do you investigate lower GI bleed
DRE Colonoscopy Bloods Angiogram if patient unstable to identify bleeding
29
What bloods
``` FBC, U+E, LFT, Ca, TFT Clotting Amylase CRP Group and save Stool MC+S Coeliac Calprotectin QFIB ```
30
What imaging
AXR if sign of sepsis / peritonitis
31
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 ```
32
Can you put bleeding down to haemorrhoids
Not without internal inspection as can be impalpable
33
What artery affected
Gastroduodenal
34
When should you consider admission
>60 Co-mornid Unstable Aspirin / NSAID use
35
Why do you do U+E
Colonoscopy require lots of laxatives before
36
Why is ferritin useful
Drops before Hb
37
What is TIPS
Connection between inflow portal vein and outflow hepatic vein Used to reduce portal HTN