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2ND YEAR SYSTEMS: GI > Acute GI bleeding > Flashcards

Acute GI bleeding Flashcards

1
Q

Upper GI bleeding

A

bleeding from oesophagus, stomach or duodenum

Proximal to ligament of Trietz - duodenojejunal junction

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2
Q

Lower GI bleeding

A

Bleeding distal to duodenum (jejunum, ileum, colon)

Distal to ligament of Trietz

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3
Q

common clinical features of upper GI bleeding

A

Haematemesis - vomiting blood

Melaena - black, sticky stools due to blood

Elevated Urea
Digested blood: haem -> urea

Associated with dyspepsia, reflux, epigastric pain

Non-steroidal anti-inflammatory use

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4
Q

common clinical features of lower GI bleeding

A

Fresh blood/clots - darker

Magenta stools

Normal urea (rarely elevated if proximal small bowel origin)

Typically painless

More common in advanced age

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5
Q

Causes for upper GI bleeding

A

In all areas:-
ulcers
inflammation - abnormal clotting

Oesophagus:-
Varices
Mallory weiss tear 
malignancy
Oesophagitis

Stomach:-
Gastritis
varices
portal hypertensive gastropathy

Duodenum:-
Angiodysplasia

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6
Q

3 most common causes of upper GI bleed

A

peptic ulcer
gastritis/erosions
oesophagitis

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7
Q

Pathophysiology of peptic ulceration

A

damaging forces - gastric acidity or peptic enzymes

defensive - surface mucous secretion, bicarbonate secretion into mucous etc

injury occurs when there is increased damage or impaired defences

Chronic disease - increased risk for lymphoma or carcinoma

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8
Q

Which type of ulcers are more common than gastric ones?

A

duodenal ulcers are more common

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9
Q

Risk factors for peptic ulcers? (4)

A

Helicobacter pylori - produces urease -> ammonia produced then buffers gastric acid locally => increased acid production

NSAIDs/Aspirin - prostaglandin production -> reduced mucus and bicarbonate excretion => reduced physical defences

Alcohol excess

Systemic illness – “Stress ulcers”

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10
Q

How might you miss a gastric carcinoma on examination?

A

a gastric ulcer may sit over a gastric carcinoma

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11
Q

Which condition causes recurrent poor healing duodenal ulcers?

A

Zollinger-Ellison syndrome

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12
Q

Oesophagitis: causes of upper GI bleed

A 
Reflux oesophagitis
Hiatus hernia
Alcohol
Bisphosphonates
Systemic illness
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13
Q

you are more likely to have significant bleeding if you’re on which type of drug?

A

anti-platelet (clopidogrel etc) or anti-coagulation (warfarin etc)

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14
Q

Discuss varices and link to upper GI bleeding

A

secondary to portal hypertension - due to liver cirrhosis

abnormally dilated collateral vessels

oesophageal type - most common

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15
Q

What is a Mallory-Weiss tear

A

Linear tear at the oesophago-gastric junction

tear in the mucous membrane or lining

follows period of retching or vomiting

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16
Q

What is Diuelafoy?

A

rare condition where submucosal arteriolar vessel erodes through mucosa

common in gastric fundus

17
Q

What is angiodysplasia?

A

Vascular malformation
Occurs anywhere in GI tract

Frequent cause of chronic occult or overt occult bleeding (ie bleeding without obvious signs/symptoms)

Associated with chronic conditions including heart valve replacement

18
Q

Investigation for upper GI bleeding?

A

Endoscopy - diagnostic and therapeutic. Within 24 hours, sooner if unstable

19
Q

Colonic causes for lower GI bleeding (7)

A

Diverticular disease

Haemorrhoids

Vascular malformations (angiodysplasia)

Neoplasia (carcinoma or polyps)

Ischaemic colitis

Radiation enteropathy/proctitis - degenerative changes after radiotherapy

Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)

20
Q

What is diverticular disease?

A

Very common

Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch/sac

Diverticulosis - presence
Diverticulitis - inflammation

usually self-limiting
10-20% bleeding during the lifetime

21
Q

Haemorrhoids:-
What are they?
How do they come about? Common/uncommon? Treatment?

A

Enlarged vascular cushions around anal canal

Painful if thrombosed or external

Association with straining/constipation/low fibre diet

Common, rarely causes serious bleeding

Treatment is elective surgical intervention

22
Q

Angiodysplasia:-
What are they?
How do they come about? Common/uncommon? Treatment?

A

Vascular malformation

  • Degeneration
  • Friable and bleeds easily

May be association with heart valve abnormalities

Bleeding often precipitated by anticoagulants/antiplatelets

May be multiple including small bowel

Treatment with Argon Phototherapy, medication incl tranexamic acid, thalidomide

23
Q

What is ischaemic colitis? Where does it affect? How does it present?

A

Disruption in blood supply to colon

Affects areas according to blood supply, typically descending/sigmoid colon

Presents with crampy abdominal pain and sudden bleeding

  • More common over 60 years
  • Usually self-limiting
  • Dusky blue, swollen mucosa
24
Q

Complications with ischaemic colitis?

A

Complications include gangrene and perforation

25
Q

Investigations: Acute lower GI bleeding

A

Lower GI endoscopy:

  • Flexible sigmoidoscopy – if large volume view’s limited
  • Colonoscopy – requires preparation

CT Angiography

26
Q

Small bowel causes for lower GI bleeding

A

If no colonic cause is found and upper GI bleeding excluded need to consider small bowel origin (5%)

Meckel’s diverticulum

Small bowel angiodysplasia

Small bowel tumour/GIST (GI stromal tumours)

Small bowel ulceration (NSAID associated)

Aortoentero fistulation – following AAA repair

27
Q

Investigations for small bowel

A

CT angiogram

Meckel’s scan (Nuclear scintigraphy - to detect/ diagnose a Meckel’s diverticulum)

Capsule endoscopy - camera

Double balloon enteroscopy

28
Q

Management of GI bleeding

A

risk assessment

Endoscopy within 24 hours - before if unstable

Reverse contributory medication as able

Blood products if ongoing bleeding

specific meds

consider CT

29
Q

What is the Rockall Score used to predict?

A

death, but also used to predict re-bleeding

things that are rated are Age, shock, co-morbidity, diagnosis and major stigmata of recent haemorrhage

30
Q

What is the Glasgow Blatchford score used for?

A

To decide if a patient with an acute upper GI bleeding will need to have medical intervention such as a blood transfusion or endoscopic intervention

score >6 associated with a greater than 50% risk of an intervention

31
Q

Management of GI bleeding due to peptic ulcers (4)

A

Proton pump inhibitors

Endoscopy with endotherapy

Angiography with embolization

Laparotomy

32
Q

Endoscopic therapy options for peptic ulcer (4)

A

Injection
Adrenaline 1:10000

Thermal
- Contact – “gold probe”

Mechanical
- Clip

Haemospray

Combination therapy most effective (adrenaline + thermal or clips)

33
Q

What do you do if bleeding is uncontrollable endoscopically? (2)

A

Angiography + embolization

laparotomy

34
Q

Management of varices

A

band ligation - only oesophageal

or glue injection

IV terlipressin - vasoconstrictor of splanchnic blood supply - reduced blood to portal vein

IV broad spectrum antibiotics

correct coagulopathy

35
Q

When a bleed is uncontrollable at endoscopy from varices what needs to be done?

A

Transjugular intrahepatic porto-systemic shunt

2ND YEAR SYSTEMS: GI (38 decks)

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