Bleeds, Ulcers & Diverticular diseae Flashcards
What is the risk score used for assessing the risk related to upper GI bleeds? What does it entail? WHAT IS IT GOOD FOR?
Glasgow-Blatchford Bleeding Score (GBS)
- haemoglobin
- BUN (bood urea nitrogen)
- initial systolic BP
- Sex
- HR >100
- melena
- Recent syncope
- Hepatic disease Hx
- Cardiac Failure
Decision making tool for admission or discharge from A&E
0/1= low risk, >1 = higher risk & require admission + investigation
What are the typical symptoms of an Upper GI bleed?
- Signs of circulatory insufficiency (tachy, hypotension)
- melena
- haematemesis
less specific:
- retrosternal pain/other abdo discomfort
- nausea
- increased belching
- dsyphagia
- signs of anaemia from chronic bleeds
What are the typical symptoms of a lower GI bleed?
- bright red bloody stool
- rectal bleeding
- may be melena
less specific:
- retrosternal pain/other abdo discomfort
- nausea
- increased belching
- dsyphagia
- signs of anaemia from chronic bleeds
What are the main aetiologies of an Upper GI bleed?
Erosive/inflammatory:
- gastric/duodenal ulcers
- gastritis/duodenitis/oesophagitis
- RF = GORD, NSAIDS/Aspirin, glucocorticoid steroids, Infections (H. Pylori)
Vascular:
-Oesophageal haemorrhage
Tumours
Traumatic/iatrogenic:
- Mallory-Weiss tear
- following endoscopcy/polypectomy
What are the main aetiologies of a lower GI bleed?
Erosive/inflammatory:
- diverticulosis
- IBD, Chrons, UC
- infectious diarrhea
Vascular:
- haemorrids
- ischemia
- rectal varices
Tumours:
- colorectal & anal cancer
- colon polyps
Traumatic/iatrogenic:
- post polypectomy or biopsy
- post-surgery anastomotic bleeding
What initial investigations do you in suspected upper GI or Lower GI bleed?
Upper GI signs:
-OGD
Lower GI signs:
-Colonoscopy
What is the Recommended management pathway for UGIB?
- Glasgow-Blatchford Scale - 0-1 = non-urgent, >1 = admission + investigation
- Resus with fluids, oxygen, RBC transfusion @ Hb of 70-80
- Erythromycin - prokinetic (increase gastric emptying for better endsocopy)
- PPI
How do you resus GI bleed patient?
- 2 large bore canula in the cubital fossa
- crystallises first line - NORMAL SALINE
What is the other important scoring system for GI bleeds?
Rockall Score:
pre-endoscopy + post-endoscopy
pre-endoscopy score = mortality
0-3 - >2 exponential increase in risk
- Age - (<60, 60-79, >80)
- Shock - (Pulse + BP)
- Comorbidity (Cardiac, GI Ca, major comorbidity - scores 2)
What endoscopic treatments are there?
- adrenaline injection
- ablative techniques
- banding
- mechanical devices
When & how to Post endoscopy PPI infusion?
- Severe active bleed seen on scope
- 8mg per hour for 72 hours (omeprazole)
What are the risk factors for Gastric & duodenal ulcers?
- H. Pylori infection
- long term NSAID use
- NSAID + steroid use
- SSRIs
- Smoking
- Chronic alcohol consumption
- > 65
- Stress
How does H. Pylori effect the gastric mucosa?
- Causes an increased acid production
- causes decrease in protective mucosal components
How do NSAIDs increase the risk of ulcers?
COX 1 & 2 inhibitors which cause a decrease in PGE2 that cuase a decrease in acid secretion & increases bicard + mucus secretion
-leads to mucosal erosion
What Sx are common to both Gastric & duodenal ulcers?
- Dyspepsia - postrprandial heaviness, early satiety, gnawing, aching/burning epigastric pain
- pain relief from antacids
- secondary Sx from blood loss (anaemia, melena, haematemsis)
- occult blood in stool
What Sx differentiate Gastric from duodenal ulcers & vice versa?
- Gastric - pain increases shortly after eatin + weight loss
- duodenal - pain increase 2-5 hours after eating/pain on empty stomach + weight gain
How do you test for H.pylori?
- OGD - biopsy and histology of ulcers seen on scope
- Urea breath test - good for diagnostics and proof of Tx
- H.pylori stool antigen - good for diagnostics and proof of treatment
- serum antigen ain’t that great
How you treat a H.pylori +ve patient?
- TRIPLE THERAPY
- amox 7/7 + metronidazole (or clarythro) 7/7 + PPI (omep) 4-8/52
If a patient with a peptic ulcer ISN’T H.Pylori +ve how do you treat them?
- 4-8 weeks of PPI
- stop causative agents
- lifestyle advice
Apart from bleeding, what is the other complication of peptic ulcer disease?
- Gastric outlet obstruction
- acute - oedema and inflammation
- chronic - fibrosis and scarring
What are the symptoms of gastric outlet obstruction?
- postparandial NONbillious vomiting
- early satiety
- weight loss
- sucussion splash
How do mallory-weiss tears occur?
-sudden severe increase increase in the oesophageal luminal pressure causing a tear in the mucousal and submucosal vessels
What conditions cause mallory-weiss tears?
SEVERE VOMITING
- alcoholism
- bulimia nervosa
- hitial hernia
- GORD
What are the clinical features of a patient with a mallory-weiss tear?
- could be asymptomatic
- haematemesis
- retrosternal pain
- SHOCK
How do you diagnose and treat a patient with a mallory-weiss tear?
- OGD
- OGD adrenaline or fibrin sealant injections
- cauterisation - chemical, heat or electric
-may be able to treat conservatively IF it’s stopped bleeding
What blood test MUST you do with any acutely bleeding patient?
-Group and save + crossmatch 2 units
What’s the difference between a single diverticular, diverticulosis and diverticulitis?
- diverticula - single outpouching of bowel containing all layers of the intestinal wall still in communication with the lumen
- diverticulosis - multiple diverticular present throughout the bowel without any evidence of infection m
- diverticulitis - infection of one or more diverticular
What are the symptoms of diverticulosis?
- abdominal discomfort
- chronic diarrhoea
What are the symptoms of diverticulitis?
-Left iliac fossa pain + tenderness
-possible palpable mass in LIF
-acute constipation (50%)
-acute diarrhoea (30%)
-N&V
-acute abdomen = perf and peritonitis
-
What are the tests to diagnose diverticulitis?
- bloods - infection markers
- CT abdo + pelvis + contrast
DONT SCOPE - risk of perf
What follow up is needed for a patient following an episode of acute diverticulitis?
-6-8 post event FU colonoscopy to assess for potential malignancy
How do you treat diverticulitis? Both Uncomplicated and complicated please?
Uncomplicated - oral broad spec ABX (cipro + metro)
Complicated - IV ABX, abscess drainage +/- surgery
what life style advice would you offer to a patient with resolved diverticulitis?
- HIGH fibre diet
- LOW fat diet
- lots of fluid hydration
- vigorous exercise
