Acute GI bleeding Flashcards
Upper GI bleeding
bleeding from oesophagus, stomach or duodenum
Proximal to ligament of Trietz - duodenojejunal junction
Lower GI bleeding
Bleeding distal to duodenum (jejunum, ileum, colon)
Distal to ligament of Trietz
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
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
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
3 most common causes of upper GI bleed
peptic ulcer
gastritis/erosions
oesophagitis
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
Which type of ulcers are more common than gastric ones?
duodenal ulcers are more common
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”
How might you miss a gastric carcinoma on examination?
a gastric ulcer may sit over a gastric carcinoma
Which condition causes recurrent poor healing duodenal ulcers?
Zollinger-Ellison syndrome
Oesophagitis: causes of upper GI bleed
Reflux oesophagitis Hiatus hernia Alcohol Bisphosphonates Systemic illness
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)
Discuss varices and link to upper GI bleeding
secondary to portal hypertension - due to liver cirrhosis
abnormally dilated collateral vessels
oesophageal type - most common
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
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
