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Yr2 GI Joe > Acute GI bleeding > Flashcards

Acute GI bleeding Flashcards

1
Q

In terms of GI bleeding - when is it considered Upper GI or lower GI?

A

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
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2
Q

What are the cardinal features of upper GI bleeds

A

Haematemesis

Melaena - Upper GI means black, tarry stool

Elevated urea - from digestion of haem

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3
Q

What are the main features of Lower GI bleeds?

A

Stool containing fresher blood/clots - usually magenta in colour

Normal urea - as less digestion of haem

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4
Q

How do upper and lower GI bleeds differ symptomatically?

A

Upper GI:

  • Tends to be more overt (symptomatic)
  • Haematemesis/vomiting
  • Dyspepsia, reflux, epigastric pain

Lower GI:

  • Typically painless
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5
Q

What are the common causes of Upper GI bleeds?

A

Peptic ulceration (most common)

Infection (oesophagitis, gastritis etc)

Many causes specific to area (oesophagus, stomach, doudenum)

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6
Q

What oesophageal problems can cause Upper GI bleeding?

A

Oesophageal ulcer

Oesophagitis

Oesophageal variceal rupture/bleeding

Mallory Weiss tear

Oesophageal Malignancy

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7
Q

What problems in the stomach can cause bleeding?

A

Gastric ulcer

Gastritis

Varices

Malignancy

Angiodysplasia

Portal hypertensive gastropathy

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8
Q

What problems in the duodenum can cause bleeding?

A

Duodenal ulcer

Duodenitis

Angiodysplasia

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9
Q

Variceal bleeding is one of the causes of upper GI bleeding.

Why might it occur?

A

Variceal bleeding can occur secondary to portal hypertension

Usually due to liver cirrhosis (so associated with alcohol abuse etc)

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10
Q

What is Diuelafoy?

A

Submucosal arteriolar vessel eroding through mucosa

occurs in Gastric fundus - and is rarer cause of upper GI bleeding

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11
Q

What is angiodysplasia?

A

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

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12
Q

Give an overview of the investigations for GI bleeding.

A

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
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13
Q

What are the causes of acute lower GI bleeding?

A

Diverticular disease

Haemorrhoids

Angiodysplasia (and other vascular malformations)

Neoplasia (or polyps)

Ischaemic colitis

Radiation enteropathy/proctitis

IBD

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14
Q

How is diagnosis of the causes of lower GI bleeding made?

A

Requires flexible sigmoidoscopy or full colonoscopy

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15
Q

What is diverticular disease?

A

Protrusions of the inner mucosal lining through the outer muscular layer forming pouches

Diverticulosis = presence of pouches

Diverticulitis = inflammation

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16
Q

What are haemorrhoids?

A

Enlarged vascular cushions around anal canal

Become painful when thrombosed or external

17
Q

What patient history is associated with haemorrhoids?

A

h.o - straining/constipation and low fibre diet

18
Q

Angiodysplasia is a cause of both upper and lower GI bleeds. In lower GI - what can cause angiodysplasia to occur?

A

Heart valve abnormalities

Antiplatelets and anticoagulants can precipitate bleeding

19
Q

How is lower GI angiodysplasia treated?

A

Treatment with Argon Phototherapy, medication incl tranexamic acid, thalidomide

20
Q

What is ischaemic colitis, how does it present and what would investigation show?

A

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

21
Q

What are the complications of ischaemic colitis?

A

Gangrene

Perforation

22
Q

How is lower GI bleeding investigated?

A

Lower GI endoscopy options:

  • Proctoscopy
  • Flexible sigmoidoscopy
  • Colonoscopy (requires prep)

CT angiography - identifies vascular abnormalities; angiodysplasia, ischaemic colitis

23
Q

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?

A

Meckel’s diverticulum

Angiodysplasia

Neoplasia

Small bowel ulcerations (NSAID associated)

Aortoentero fistulation (following AAA repair)

24
Q

How would you investigate small bowel bleeding?

A

CT angiography

Meckel’s scan (ie Nuclear Scintigraphy is diagnostic)

Capsule endoscopy

Double balloon enteroscopy

25
Q

Gastrointestinal haemorrhage or severe acute bleeding is an emergency so an ABCDE approach is taken

How is circulation managed in GI haemorrhage?

A

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?

26
Q

After immediate management (patient stabilised) - describe the management of a patient with GI haemorrhage

A

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

27
Q

If a patient with a gastrointestinal haemorrhage continues to actively bleed. What additional management takes place?

A

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

28
Q

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?

A

“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

29
Q

What is circulatory shock?

A

Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia

30
Q

What signs are present with shock?

A

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

31
Q

Peptic ulcers are the most common cause of GI bleeding.

What options are available for its management when it causes bleeding?

A

Proton pump inhibitors (eg omeprazole)

Endoscopy with endotherapy

Angiography with embolisation

Laparotomy

32
Q

What types of endotherapy can be used to treat peptic ulcers that are causing bleeding?

A

Combination therapy - (adrenaline + thermal or clips)

33
Q

If endoscopy reveals a peptic ulcer that is uncontrollably bleeding and has caused UGIB - how is this managed?

A

Angiography and embolization

Laparotomy

34
Q

How are varices managed in the following places:

a) Oesophagus
b) Stomach (gastric varices)
c) Rectum

A

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

35
Q

If varices are identified as causing UGIB, what non-surgical management is required?

A

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

36
Q

If variceal bleeding is uncontrolled at endoscopy - what surgical management is indicated?

A

Sengstaken-Blakemore tube

Transjugular intrahepatic porto-systemic shunt

37
Q
A

Yr2 GI Joe (28 decks)

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