Acute GI bleeding Flashcards
In terms of GI bleeding - when is it considered Upper GI or lower GI?
Upper GI
- bleeding from oesophagus, stomach or duodenum
- (proximal to ligament of Trietz)
Lower GI
- bleeding from jejunum, ileum, colon
- Distal to ligament of Trietz
What are the cardinal features of upper GI bleeds
Haematemesis
Melaena - Upper GI means black, tarry stool
Elevated urea - from digestion of haem
What are the main features of Lower GI bleeds?
Stool containing fresher blood/clots - usually magenta in colour
Normal urea - as less digestion of haem
How do upper and lower GI bleeds differ symptomatically?
Upper GI:
- Tends to be more overt (symptomatic)
- Haematemesis/vomiting
- Dyspepsia, reflux, epigastric pain
Lower GI:
- Typically painless
What are the common causes of Upper GI bleeds?
Peptic ulceration (most common)
Infection (oesophagitis, gastritis etc)
Many causes specific to area (oesophagus, stomach, doudenum)
What oesophageal problems can cause Upper GI bleeding?
Oesophageal ulcer
Oesophagitis
Oesophageal variceal rupture/bleeding
Mallory Weiss tear
Oesophageal Malignancy
What problems in the stomach can cause bleeding?
Gastric ulcer
Gastritis
Varices
Malignancy
Angiodysplasia
Portal hypertensive gastropathy
What problems in the duodenum can cause bleeding?
Duodenal ulcer
Duodenitis
Angiodysplasia
Variceal bleeding is one of the causes of upper GI bleeding.
Why might it occur?
Variceal bleeding can occur secondary to portal hypertension
Usually due to liver cirrhosis (so associated with alcohol abuse etc)
What is Diuelafoy?
Submucosal arteriolar vessel eroding through mucosa
occurs in Gastric fundus - and is rarer cause of upper GI bleeding
What is angiodysplasia?
Vascular malformation that can occur anywhere in GI tract (thus can cause upper/lower GI bleeds)
Fairly uncommon cause of bleeding - quite often occult
Associated with heart valve replacements
Give an overview of the investigations for GI bleeding.
Upper GI endoscopy
- most important investigatory tool - is both diagnostic and therapeutic
Bloods
- Important to check Haemoglobin, urea & electrolytes, liver biochemistry and coagulation screen
- more on another card
What are the causes of acute lower GI bleeding?
Diverticular disease
Haemorrhoids
Angiodysplasia (and other vascular malformations)
Neoplasia (or polyps)
Ischaemic colitis
Radiation enteropathy/proctitis
IBD
How is diagnosis of the causes of lower GI bleeding made?
Requires flexible sigmoidoscopy or full colonoscopy
What is diverticular disease?
Protrusions of the inner mucosal lining through the outer muscular layer forming pouches
Diverticulosis = presence of pouches
Diverticulitis = inflammation
What are haemorrhoids?
Enlarged vascular cushions around anal canal
Become painful when thrombosed or external
What patient history is associated with haemorrhoids?
h.o - straining/constipation and low fibre diet
Angiodysplasia is a cause of both upper and lower GI bleeds. In lower GI - what can cause angiodysplasia to occur?
Heart valve abnormalities
Antiplatelets and anticoagulants can precipitate bleeding
How is lower GI angiodysplasia treated?
Treatment with Argon Phototherapy, medication incl tranexamic acid, thalidomide
What is ischaemic colitis, how does it present and what would investigation show?
Ischaemia of parts of colon due to disruption in blood supply
Presents with crampy abdominal pain and lower GI bleeding - typically in patients over 60
Lower GI endoscopy would show dusky blue, swollen mucosa
What are the complications of ischaemic colitis?
Gangrene
Perforation
How is lower GI bleeding investigated?
Lower GI endoscopy options:
- Proctoscopy
- Flexible sigmoidoscopy
- Colonoscopy (requires prep)
CT angiography - identifies vascular abnormalities; angiodysplasia, ischaemic colitis
Acute GI bleeding originating in the small bowel is rare.
Once large bowel and upper GI causes are excluded - this should be investigated.
What are the causes of bleeding from the small bowel?
Meckel’s diverticulum
Angiodysplasia
Neoplasia
Small bowel ulcerations (NSAID associated)
Aortoentero fistulation (following AAA repair)
How would you investigate small bowel bleeding?
CT angiography
Meckel’s scan (ie Nuclear Scintigraphy is diagnostic)
Capsule endoscopy
Double balloon enteroscopy
Gastrointestinal haemorrhage or severe acute bleeding is an emergency so an ABCDE approach is taken
How is circulation managed in GI haemorrhage?
Establish wide bored IV access and administer:
- IV fluids!
- Blood transfusion - if in shock / Hb < 7g/dL active bleeding
Urgent blood samples:
- FBC, U&Es, LFTs, Coagulation, blood group and save/ crossmatch
Catheter
Tranexamic acid?
After immediate management (patient stabilised) - describe the management of a patient with GI haemorrhage
Endoscopy once stable:
- aim within 24 hours but sooner if unstable
Withhold/reverse medications that contributed to the bleeding:
- If on warfarin - give Vitamin K or Factor IX complex
Consider CT angiography/interventional radiology/surgical interventions as appropriate
If a patient with a gastrointestinal haemorrhage continues to actively bleed. What additional management takes place?
If a patient has active bleeding which continues, then they should ALSO be given blood products and surgery
IV platelets if < 50,000 platelets (< 50)
FFP if INR or APTT* if > 1.5x normal range
Cryoprecipitate if fibrinogen < 1.5 g/L
In gastrointestinal haemorrhage - if the patient has ongoing bleeding then another card talk about how you can give them FFP
What was that all about?
“FFP if INR or ATPP > 1.5x normal average”
- FFP - Fresh frozen plasma
- INR - International Normalised Ratio
- APTT - activated Partial Thromboplastin Time
Both INR/ATPP scores higher than normal indicate the patient has impaired clotting ability - which can account for the ongoing bleeding
FFP is a fast replacement for blood proteins and coagulation stuff thats been lost
What is circulatory shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
What signs are present with shock?
Tachypnoea
Tachycardia
Hypotension
Anxiety or confusion
Cool clammy skin
Oliguria - l**ow urine output
Just think how you’d be if you randomly lost a ton of blood
Peptic ulcers are the most common cause of GI bleeding.
What options are available for its management when it causes bleeding?
Proton pump inhibitors (eg omeprazole)
Endoscopy with endotherapy
Angiography with embolisation
Laparotomy
What types of endotherapy can be used to treat peptic ulcers that are causing bleeding?
Combination therapy - (adrenaline + thermal or clips)
If endoscopy reveals a peptic ulcer that is uncontrollably bleeding and has caused UGIB - how is this managed?
Angiography and embolization
Laparotomy
How are varices managed in the following places:
a) Oesophagus
b) Stomach (gastric varices)
c) Rectum
All managed through Endotherapy:
a) Oesophagus
- Band ligation
- Glue injection
b) Gastric
* Glue injection
c) Rectal
* Glue injection
Patient should be intubated to ensure airway protection
If varices are identified as causing UGIB, what non-surgical management is required?
IV Terlipressin
- Vasoconstrictor of splanchnic blood supply
IV broad-spectrum antibiotics
- As variceal UGIB often precipitated by systemic infection
Correct any coagulopathy that patient may have
If variceal bleeding is uncontrolled at endoscopy - what surgical management is indicated?
Sengstaken-Blakemore tube
Transjugular intrahepatic porto-systemic shunt
