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GI > Acute GI Bleeding > Flashcards

Acute GI Bleeding Flashcards

1
Q

Where does bleeding in the upper GI tract occur?

A
  • Bleeding from oesophagus, stomach or duodenum
  • Proximal to ligament of Trietz

Lower GI bleed is:

  • Bleeding distal to duodenum (jejunum, ileum, colon)
  • Distal to ligament of Trietz
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2
Q

What are signs and symptoms of upper GI bleed?

A
  • Haematemesis
  • Melaena
  • Elevated Urea
  • Partially digested blood -> haem -> urea
  • Associated with dyspepsia, reflux, epigastric pain
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3
Q

What drugs are upper GI bleeds associated with?

A

•Non-steroidal anti-inflammatory use

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4
Q

What are signs and symptoms of lower GI bleed?

A
  • Fresh blood/clots
  • Magenta stools
  • Normal urea (rarely elevated in proximal small bowel)
  • Typically painless
  • More common in advanced age
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5
Q

What are the causes of upper GI bleeding?

A

ULCERS

Oesophagus:

  • Oesophageal varices
  • Mallory Weiss Tear (tear in the mucous membrane, or inner lining, where the esophagus meets the stomach)
  • Oesophageal malignancy

Stomach:

  • Gastric varices
  • Gastric malignancy (may be under an ulcer)
  • Dieulafoy - a large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes through mucosa and bleeds
  • Angiodysplasia ** tends to be chronic (angiodysplasia is a small vascular malformation of the gut associated with chronic heart conditions such as heart valve replacement)

Duodenum

  • Angiodysplasia
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6
Q

What are the damaging forces that can cause a peptic ulcer?

A

Under normal circumstances:

Gatric acidity

Peptic enzymes

Injury as a result of:

H.Pylori Infection

NSAIDS

Aspirin

Cigarettes

Alcohol

Gastric hyperacidity

Duodenal gastric reflux

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7
Q

What are the defensive forces of the upper GI tract?

A

Surface mucus secretion

Bicarbonate secretion in to mucus

Epithelial regenerative capacity

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8
Q

What can result in impaired defence mechanisms in the upper GI?

A

Ischaemia

Shock

Delayed gastric emptying

Host factors

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9
Q

What is the risk associated with chronic peptic ulcers?

A

Increased risk of lymphoma and carcinoma

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10
Q

Where is the most common place for upper GI ulcers?

A

Duodenal ulcers more common than gastric (75%)

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11
Q

What are risk factors for upper GI bleed?

A
  • Helicobacter pylori
  • produces urease -> ammonia produced

-> buffers gastric acid => 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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12
Q

What may conceal gastric carcinoma?

A

Gastric ulcers may sit over a gastric carcinoma

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13
Q

What is Zollinger - Ellison syndrome?

A

Gastrin - secretin pancreatic tumour - causes recurrent poor healing duodenal ulcers

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14
Q

What causes bleeding in the case of gastritis and duodenitis?

A

•Tend to bleed in context of impaired coagulation

  • Medical conditions
  • Anti-coagulants (warfarin, rivaroxaban, apixaban, dabigatran, LMWH)
  • Anti-platelets (clopidogrel, ticagrelor)
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15
Q

What are the causes of oesophagitis?

A
  • Reflux oesophagitis
  • Hiatus hernia
  • Alcohol
  • Bisphosphonates
  • Systemic illness

More likely to have significant bleeding if on anti-platelet (clopidogrel, ticagrelor) or anti-coagulation (warfarin, rivaroxaban, apixaban, dabigatran)

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16
Q

What causes an enlarged spleen?

A

Portal hypertension - this can be as a result of liver cirrhosis

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17
Q

What causes portal hypertension?

A

Liver cirrhosis

Blood clots in the portal vein

Blood clots in hepatic veins

Parasitic infection called schistosomiasis, and focal nodular hyperplasia, a disease seen in people infected with HIV

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18
Q

Where do you find abnormally dilated collateral vessels in portal hypertension?

A

•Oesophageal (90%)
Gastric (8%)
Rectal and splenic (rare)

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19
Q

What can cause the bleeds in the varices?

A

Increases in portal pressure (eg infection/drug use)

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20
Q

What are the malgnant conditions that can cause upper GI bleeding?

A
  • Oesophageal cancer
  • May have dysphagia /weight loss history
  • Typically “ooze”

•Gastric cancer

  • Can present as an ulcer
  • GU needs interval endoscopy for healing
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21
Q

When does mallory-weiss tear often present?

A

Period of wrethcing / vomiting

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22
Q

Where can angiodysplasia occur in the GI tract?

A

Anywhere in the GI tract

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23
Q

What are the colonic causes of acute lower GI bleeding?

A
  • Diverticular disease
  • Haemorrhoids
  • Vascular malformations (angiodysplasia)
  • Neoplasia (carcinoma or polyps)
  • Ischaemic colitis
  • Radiation enteropathy/proctitis
  • Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)
24
Q

How do you diagnose acute colonic causes of bleeding?

A

Diagnosis requires flexible sigmoidoscopy or full colonoscopy

25
Q

What is diverticular disease?

A

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

26
Q

What is the difference between diverticulosis and diverticulitits?

A
  • Diverticulosis - presence
  • Diverticulitis - inflammation
27
Q

What is the normal prognosis of diverticular disease?

A

Usually self-limiting (75%)

28
Q

What are haemorrhoids?

A

•Enlarged vascular cushions around anal canal

29
Q

When are haemorrhiods painful?

A

If thrombosed or external

30
Q

What are haemorrhoids associated with?

A

•Association with straining/constipation/low fibre diet

31
Q

What is treatment of haemorrhoids?

A

•Treatment is elective surgical intervention

32
Q

What is treatment of angiodysplasia?

A

Argon therapy

33
Q

What are the common types of colonic neoplasia?

A

•Colonic polyps or carcinoma

34
Q

Does colonic neoplasia cause life threatening bleeding?

A

Rarely

35
Q

Which part of the colon does ischaemic colitis normally affect?

A

Descending/sigmoid colon

36
Q

What are complications of ischaemic colitis?

A

Gangrene and perforation

37
Q

How does ischaemic colitis normally present?

A

Crampy abdominal pain, usually self-limiting

More comon in those over 60

38
Q

What radiotherapy treatment might cause radiation proctits?

A

Cervical cancer

Prostate cancer

39
Q

What is treatment of radiation proctitis?

A
  • APC
  • Sulcrafate enemas
  • Hyperbaric oxygen
40
Q

What are the causes of small bowel bleeding?

A

Meckel’s diverticulum

Small bowel angiodysplasia

Small bowel tumur /GIST

Small bowel ulceration (NSAID associated)

Aortoentero fistulation - following AAA repair

41
Q

Whata re the acute lower GI bleeding investigations?

A
  • CT angiogram
  • Meckel’s scan (Scintigraphy)
  • Capsule endoscopy
  • Double balloon enteroscopy
42
Q

What is diagnostic for meckel’s diverticulum?

A

•Nuclear Scintigraphy is diagnostic

43
Q

What is meckels diverticulum?

A

A congenital bulge from the small intestin resulting from the remnant of the vitelline duct

44
Q

What is management of GI bleeding?

A

•A. Airway

•B. Breathing

•C. Circulation:

  • Wide bored IV access => IV fluids, blood transfusion
  • Urgent blood samples to lab: FBC, UE, LFT, Coagulation, blood group and save/ cross match
  • Blood transfusion if Hb<7g/dl or ongoing active bleeding
  • Evidence that transfusing Hb>10g/dl has worse outcomes
  • Catheter

•D. Disability

•E. Exposure

  • Withhold/reverse contributory medications as able*
  • Vitamin K if on warfarin
45
Q

What is done to the patient after they are stable from their bleed?

A

•Endoscopy once stable – within 24 hours

•Upper GI endoscopy more likely to have therapeutic options

•Consider CT angiography/interventional radiology/surgical interventions as appropriate

46
Q

What is meant by shock?

A

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

47
Q

What are the features of shock?

A
  • a high respiratory rate (tachypnoea)
  • a rapid pulse (tachycardia)
  • anxiety or confusion
  • cool clammy skin
  • low urine output (oliguria)
  • low blood pressure (hypotension)
48
Q

What is management of GI bleeding: Peptic Ulcer?

A
  • Proton pump inhibitors
  • Endoscopy with endotherapy
  • Angiography with embolization
  • Laparotomy
49
Q

What is the risk associated with endoscopy?

A

Re-bleeding

50
Q

What are the endoscopic therapy options for peptic ulcer?

A

•Injection

•Adrenaline 1:10000

•Thermal

•Contact – “gold probe”

•Mechanical

•Clip

•Haemospray

Combination therapy most effective (adrenaline + thermal or clips)

51
Q

What is the treatment for uncontrollable bleeding endoscopically?

A

Angiography and embolization

Laparotomy

52
Q

What is the endotherapy for oesophageal varices?

A

Band ligation

Glue injection

53
Q

What is the endotherapy for gastric and rectal causes of GI bleeding?

A

Glue injection

54
Q

Why are patients intubated with presence of varices?

A

Airway protection

55
Q

What are other ways of managing varices?

A

•IV Terlipressin

Vasoconstrictor of splanchnic blood supply

  • Reduces blood flow to portal vein, reducing portal pressures
  • Mortality fell from 32% to 12%

•IV Broad spectrum antibiotics

•Often precipitated by systemic infection

•Correct coagulopathy

56
Q

What is management of Varices bleeding when uncontrolled at endoscopy?

A

GI (38 decks)

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