Acute GI bleeding Flashcards by Anna Coull

Upper GI bleeding

bleeding from oesophagus, stomach or duodenum

Proximal to ligament of Trietz - duodenojejunal junction

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Lower GI bleeding

Bleeding distal to duodenum (jejunum, ileum, colon)

Distal to ligament of Trietz

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common clinical features of upper GI bleeding

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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common clinical features of lower GI bleeding

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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Causes for upper GI bleeding

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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3 most common causes of upper GI bleed

peptic ulcer
gastritis/erosions
oesophagitis

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Pathophysiology of peptic ulceration

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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Which type of ulcers are more common than gastric ones?

duodenal ulcers are more common

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Risk factors for peptic ulcers? (4)

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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How might you miss a gastric carcinoma on examination?

a gastric ulcer may sit over a gastric carcinoma

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Which condition causes recurrent poor healing duodenal ulcers?

Zollinger-Ellison syndrome

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Oesophagitis: causes of upper GI bleed

Reflux oesophagitis
Hiatus hernia
Alcohol
Bisphosphonates
Systemic illness

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

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

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Discuss varices and link to upper GI bleeding

secondary to portal hypertension - due to liver cirrhosis

abnormally dilated collateral vessels

oesophageal type - most common

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What is a Mallory-Weiss tear

Linear tear at the oesophago-gastric junction

tear in the mucous membrane or lining

follows period of retching or vomiting

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What is Diuelafoy?

rare condition where submucosal arteriolar vessel erodes through mucosa

common in gastric fundus

What is angiodysplasia?

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

Investigation for upper GI bleeding?

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

Colonic causes for lower GI bleeding (7)

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)

What is diverticular disease?

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

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

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

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

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

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

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

Complications with ischaemic colitis?

Complications include gangrene and perforation

Investigations: Acute lower GI bleeding

Lower GI endoscopy: - Flexible sigmoidoscopy – if large volume view's limited - Colonoscopy – requires preparation CT Angiography

Small bowel causes for lower GI bleeding

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

Investigations for small bowel

CT angiogram Meckel’s scan (Nuclear scintigraphy - to detect/ diagnose a Meckel's diverticulum) Capsule endoscopy - camera Double balloon enteroscopy

Management of GI bleeding

risk assessment Endoscopy within 24 hours - before if unstable Reverse contributory medication as able Blood products if ongoing bleeding specific meds consider CT

What is the Rockall Score used to predict?

death, but also used to predict re-bleeding things that are rated are Age, shock, co-morbidity, diagnosis and major stigmata of recent haemorrhage

What is the Glasgow Blatchford score used for?

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

Management of GI bleeding due to peptic ulcers (4)

Proton pump inhibitors Endoscopy with endotherapy Angiography with embolization Laparotomy

Endoscopic therapy options for peptic ulcer (4)

Injection Adrenaline 1:10000 Thermal - Contact – “gold probe” Mechanical - Clip Haemospray Combination therapy most effective (adrenaline + thermal or clips)

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

Angiography + embolization laparotomy

Management of varices

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

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

Transjugular intrahepatic porto-systemic shunt