Acute GI Bleeding Flashcards
Where does bleeding in the upper GI tract occur?
- 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
What are signs and symptoms of upper GI bleed?
- Haematemesis
- Melaena
- Elevated Urea
- Partially digested blood -> haem -> urea
- Associated with dyspepsia, reflux, epigastric pain
What drugs are upper GI bleeds associated with?
•Non-steroidal anti-inflammatory use
What are signs and symptoms of lower GI bleed?
- Fresh blood/clots
- Magenta stools
- Normal urea (rarely elevated in proximal small bowel)
- Typically painless
- More common in advanced age
What are the causes of upper GI bleeding?
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
What are the damaging forces that can cause a peptic ulcer?
Under normal circumstances:
Gatric acidity
Peptic enzymes
Injury as a result of:
H.Pylori Infection
NSAIDS
Aspirin
Cigarettes
Alcohol
Gastric hyperacidity
Duodenal gastric reflux
What are the defensive forces of the upper GI tract?
Surface mucus secretion
Bicarbonate secretion in to mucus
Epithelial regenerative capacity
What can result in impaired defence mechanisms in the upper GI?
Ischaemia
Shock
Delayed gastric emptying
Host factors
What is the risk associated with chronic peptic ulcers?
Increased risk of lymphoma and carcinoma
Where is the most common place for upper GI ulcers?
Duodenal ulcers more common than gastric (75%)
What are risk factors for upper GI bleed?
- 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”
What may conceal gastric carcinoma?
Gastric ulcers may sit over a gastric carcinoma
What is Zollinger - Ellison syndrome?
Gastrin - secretin pancreatic tumour - causes recurrent poor healing duodenal ulcers
What causes bleeding in the case of gastritis and duodenitis?
•Tend to bleed in context of impaired coagulation
- Medical conditions
- Anti-coagulants (warfarin, rivaroxaban, apixaban, dabigatran, LMWH)
- Anti-platelets (clopidogrel, ticagrelor)
What are the causes of oesophagitis?
- 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)
What causes an enlarged spleen?
Portal hypertension - this can be as a result of liver cirrhosis
What causes portal hypertension?
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
Where do you find abnormally dilated collateral vessels in portal hypertension?
•Oesophageal (90%)
Gastric (8%)
Rectal and splenic (rare)
What can cause the bleeds in the varices?
Increases in portal pressure (eg infection/drug use)
What are the malgnant conditions that can cause upper GI bleeding?
- Oesophageal cancer
- May have dysphagia /weight loss history
- Typically “ooze”
•Gastric cancer
- Can present as an ulcer
- GU needs interval endoscopy for healing
When does mallory-weiss tear often present?
Period of wrethcing / vomiting
Where can angiodysplasia occur in the GI tract?
Anywhere in the GI tract
What are the colonic causes of acute lower GI bleeding?
- Diverticular disease
- Haemorrhoids
- Vascular malformations (angiodysplasia)
- Neoplasia (carcinoma or polyps)
- Ischaemic colitis
- Radiation enteropathy/proctitis
- Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)
How do you diagnose acute colonic causes of bleeding?
Diagnosis requires flexible sigmoidoscopy or full colonoscopy
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
What is the difference between diverticulosis and diverticulitits?
- Diverticulosis - presence
- Diverticulitis - inflammation
What is the normal prognosis of diverticular disease?
Usually self-limiting (75%)
What are haemorrhoids?
•Enlarged vascular cushions around anal canal
When are haemorrhiods painful?
If thrombosed or external
What are haemorrhoids associated with?
•Association with straining/constipation/low fibre diet
What is treatment of haemorrhoids?
•Treatment is elective surgical intervention
What is treatment of angiodysplasia?
Argon therapy
What are the common types of colonic neoplasia?
•Colonic polyps or carcinoma
Does colonic neoplasia cause life threatening bleeding?
Rarely
Which part of the colon does ischaemic colitis normally affect?
Descending/sigmoid colon
What are complications of ischaemic colitis?
Gangrene and perforation
How does ischaemic colitis normally present?
Crampy abdominal pain, usually self-limiting
More comon in those over 60
What radiotherapy treatment might cause radiation proctits?
Cervical cancer
Prostate cancer
What is treatment of radiation proctitis?
- APC
- Sulcrafate enemas
- Hyperbaric oxygen
What are the causes of small bowel bleeding?
Meckel’s diverticulum
Small bowel angiodysplasia
Small bowel tumur /GIST
Small bowel ulceration (NSAID associated)
Aortoentero fistulation - following AAA repair
Whata re the acute lower GI bleeding investigations?
- CT angiogram
- Meckel’s scan (Scintigraphy)
- Capsule endoscopy
- Double balloon enteroscopy
What is diagnostic for meckel’s diverticulum?
•Nuclear Scintigraphy is diagnostic
What is meckels diverticulum?
A congenital bulge from the small intestin resulting from the remnant of the vitelline duct
What is management of GI bleeding?
•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
What is done to the patient after they are stable from their bleed?
•Endoscopy once stable – within 24 hours
•Upper GI endoscopy more likely to have therapeutic options
•Consider CT angiography/interventional radiology/surgical interventions as appropriate
What is meant by shock?
Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia
What are the features of shock?
- a high respiratory rate (tachypnoea)
- a rapid pulse (tachycardia)
- anxiety or confusion
- cool clammy skin
- low urine output (oliguria)
- low blood pressure (hypotension)
What is management of GI bleeding: Peptic Ulcer?
- Proton pump inhibitors
- Endoscopy with endotherapy
- Angiography with embolization
- Laparotomy
What is the risk associated with endoscopy?
Re-bleeding
What are the endoscopic therapy options for peptic ulcer?
•Injection
•Adrenaline 1:10000
•Thermal
•Contact – “gold probe”
•Mechanical
•Clip
•Haemospray
Combination therapy most effective (adrenaline + thermal or clips)
What is the treatment for uncontrollable bleeding endoscopically?
Angiography and embolization
Laparotomy
What is the endotherapy for oesophageal varices?
Band ligation
Glue injection
What is the endotherapy for gastric and rectal causes of GI bleeding?
Glue injection
Why are patients intubated with presence of varices?
Airway protection
What are other ways of managing varices?
•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
What is management of Varices bleeding when uncontrolled at endoscopy?
