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Medicine, Year 3, GI and Surgery > Clinical Topic 2: GI Bleeding > Flashcards

Clinical Topic 2: GI Bleeding Flashcards

1
Q

What are the two scoring systems used in patients with Upper GI Bleeding?

A

Blatchford Score

Rockall Score

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2
Q

When is the Blatchford Score used, what is the range of the scoring, what is assessed and what is a poor score to have?

A

Used in initial assessments of patients with Upper GI Bleeding

Ranges from 0 to 23

Assessed by Blood urea nitrogen, Hb levels, Systolic BP, HR, melena, hepatic and cardiac disease

High risk of bleeding with score >0

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3
Q

When is the Rockall Score used, what is assessed and what is a good and poor score to have?

A

Used after patients have endoscopy for Upper GI Bleeding

Assesses ABCDE:
Age, Blood pressure (Shock),Co-morbidity, Diagnosis, Evidence of Bleeding

Score <3 = good, >8 = high mortality

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4
Q

What are the NICE Guidelines for Endoscopic treatment for non-variceal Upper GI bleeds?

A
  • Do not give adrenaline as a mono-therapy
    1. Clips ± adrenaline
    2. Thermal coagulation + adrenaline
    3. Fibrin/thrombin + adrenaline
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5
Q

What are the NICE Guidelines for treatment for variceal Upper GI bleeds?

A

Terlipression + antibiotics

  • Oesophageal varices: Banding (1st line), TIPS (2nd line)
  • Gastric varices: Cyanoacrylate (1st line), TIPS (2nd line)
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6
Q

What is Boerhaave syndrome? What is it usually caused by?

A

Spontaneous perforation of Oesophagus, usually due to medical instrumentation i.e. Endoscopy

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7
Q

What is the clinical significance of the Ligament of Treitz (Suspensory muscle of Duodenum)?

A

Anatomical landmark to differentiate between Upper and Lower GI Bleeding

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8
Q

What is a Deulefoy’s lesion?

A

Large tortuous arteriole most commonly in the stomach submucosa that erodes and bleeds

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9
Q

What is the microbiology of H. pylori, a bacteria which can cause upper GI ulcers

A

Gram negative, curved rod shaped, helical bacilli

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10
Q

What is the role of Parietal cells, where are they located, and what can they be influenced by?

A

Release of HCl, located in the fundus and body, and are influenced by G cells which secrete Gastrin to cause further HCl release by Parietal cells

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11
Q

What are the common locations of Gastric and Duodenal ulcers?

A

Gastric: Lesser curve of stomach
Duodenal: After the pyloric sphincter

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12
Q

What is Zollinger-Ellison Syndrome?

A

Neuroendocrine gastrinoma located in the duodenum or pancreas, releasing gastrin which simulates Parietal cells to release more HCl causing ulceration

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13
Q

In Gastric ulcers, which artery may be invaded by an ulcer and cause massive bleeding?

A

Left gastric artery

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14
Q

In Duodenal ulcers, which artery may be invaded by an ulcer and cause massive bleeding?

A

Gastroduodenal artery

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15
Q

How might a perforated Peptic ulcer cause referred pain?

A

Air collection under the diaphragm, causing phrenic nerve irritation and referred pain to the shoulder

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16
Q

How do longstanding duodenal ulcers cause Gastric Outlet Obstruction?

A

Longstanding oedema and scarring prevents passage of gastric contents

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17
Q

Why do gastric ulcers cause post-prandial abdominal pain?

A

Release of HCl due to eating

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18
Q

Why is duodenal ulcer pain relieved by eating?

A

Release of Bicarbonate from Brunner glands which neutralises HCl

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19
Q

Mallory Weiss tears affect which layer of the oesophagus? What kind of tears are they?

A

Only the mucosa, and longitudinal linear tears

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20
Q

What is the difference between Mallory Weiss tear and Boarhaave’s syndrome?

A

Mallory Weiss - only mucosal tear
Boarhaave’s syndrome - full thickness tear, can also hear Hamman’s sign (crunching sounds on auscultation due to pneumomediastinum)

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21
Q

What is Haematochezia?

A

Fresh red blood per rectum

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22
Q

Intussusception commonly occurs in what age group?

A

Mainly infants, 2/3rds of which before the age of 1. Can also occur in adults

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23
Q

What is the most common cause of bowel obstruction?

A

Intussusception

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24
Q

Which region of the GI tract does Intussusception commonly occur?

A

Ileocaecal region, where the ileum folds into the caecum

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25
Q

What is the common leading edge in infants with Intussusception?

A

Lymphoid hyperplasia, particularly Peyer’s patches

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26
Q

What are symptoms of Intussusception?

A
  • Intermittent abdominal pain
  • Red currant jelly stools
  • Sausage shaped structure in abdomen
  • Drawing knees up to chest
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27
Q

In imaging, what may be visualised in patients with Intussusception?

A

Bull’s eye, which is the telescoped intestine on end

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28
Q

What are treatment options for Intussusception?

A
  • Barium or air enema

- Surgery

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29
Q

What are the common places for Diverticula to form in Caucasian and Asian populations?

A

Caucasian populations: Sigmoid colon

Asian populations: Right sided colon

30
Q

What is a true Diverticula and a false (pseudo) Diverticula? Which are most common?

A

True diverticula are congenital and involve all four layers of the GI wall, whereas false diverticula are acquired and only involve the mucosa and submucosa, but not to the muscularis. False diverticula are more common.

31
Q

Why do diverticula commonly occur in the sigmoid colon for Caucasian populations?

A

Sigmoid colon has the narrowest lumen

32
Q

What two connective tissue disorders increase your risk of Diverticular Disease?

A
  • Marfan’s syndrome

- Enlers-Danlos syndrome

33
Q

What is the name given to a perforated diverticula connecting to the bladder? What are the symptoms?

A

Colovesicular fistula

Symptoms include air and stool content in urine, and recurrent UTIs

34
Q

What are the symptoms of Diverticulosis?

A

Intermittent LLQ abdominal pain, bloating, constipation, diarrhoea, mucoid stools

35
Q

What tests are used to detect H. pylori?

A
  • CLO test from biopsy
  • Carbon urea breath test
  • Faecal antigen test
  • Histology
  • Culture
36
Q

Explain the rationale of the Carbon Urea Breath Test to detect for H. Pylori infection

A

13C-labelled urea drink is fed to patients after an overnight fast. In the stomach the H. Pylori contains urease which breaks down 13C Urea into 13CO2. The 13CO2 travels to the lungs where it is exhaled

37
Q

What medications can increase the risk of Peptic Ulcer Disease?

A

NSAIDs
Aspirin
Bisphosphonates
Theophylline

38
Q

State two conditions which increase your likelihood of peptic ulcer formation

A

Zollinger-Ellison Syndrome

Multiple Endocrine Neoplasia Type 1 (MEN1)

39
Q

Why might patients with suspected Peptic Ulcers have false negatives on faecal antigen tests, carbon urea tests and CLO tests? What can be done to avoid this?

A

Proton pump inhibitor use can mask peptic ulcer disease. Instruct patient to stop taking PPI for 2 weeks before the test is performed

40
Q

What is the medication regime for treating H. Pylori infection?

A

3 medications, twice a day, for 1 week (3-2-1)

3 medications are 2 antibiotics and 1 proton pump inhibitor (3-2-1)

A + C
C + M
M + A

41
Q

What are some non-surgical and surgical treatments for Haemorrhoids?

A

Non surgical:

High fibre diet, Sitz baths, Steroid creams, Pramoxine hydrochloride

Surgical:

Rubber band ligation, Photocoagulation, Haemorroidectomy

42
Q

What are some risk factors for the development of Haemorroids?

A

Severe constipation, portal hypertension, pregnancy, heavy lifting / straining, obesity

43
Q

What is the significance of the Dentate / Pectinate line?

A

Internal haemorroids: Above dentate line

External haemorrhoids: Below dentate line

44
Q

What is the pathophysiology of Haemorroids?

A

Haemorroidal plexi are veins which are normal structures in the anal canal to help cushion for stool control. They can however become swollen and enlarged and protrude, causing symptoms

45
Q

What are the symptoms of internal vs external haemorroids?

A

Internal haemorroids: Painless, feeling of rectal discomfort, mucus discharge, haematochezia

External haemorroids: Sudden, severe peri-anal pain, pain on defacation

46
Q

Where do the upper, middle and lower parts of the external haemorrhoidal plexi drain into?

A

Upper -> Superior Rectal -> Inferior mesenteric
Middle -> Middle Rectal -> Internal iliac
Lower -> Inferior Rectal -> Internal pudendal

47
Q

What are the most common type of Colonic Polyps? What are they caused by? Can they be malignant?

A

Adenomatous Polyps, caused by a mutation in the APC (tumour supressor gene) on Chromosome 5. Can be malignant if they acquire other mutations in genes such as KRAS or p53

48
Q

What is the genetic inheritance pattern of Familial Adenomatous Polyposis (FAP)?

A

Autosomal Dominant

49
Q

What are the different types of neoplastic and non-neoplastic polyps based on epithelial histology?

A

Neoplastic: Adenomatous, Serrated (if large), Villous

Non-neoplastic: Tubular, Tubularvillous, Serrated (if small)

50
Q

What are the different types of polyps based on their elevation from the colonic wall? Which are most neoplastic?

A

Pedunculated
Sessile - most neoplastic
Flat

51
Q

Hamartomatous polyps are associated with what two conditions?

A

Juvenile Polyposis

Peutz-Jehger’s Syndrome

52
Q

Juvenile Polyposis is associated with a mutation in which gene?

A

SMAD-4

53
Q

What is the genetic inheritance pattern of Juvenile Polyposis?

A

Autosomal dominant

54
Q

What is the genetic inheritance pattern of Peutz-Jehger’s Syndrome?

A

Autosomal dominant

55
Q

Peutz-Jehger’s is associated with a mutation in which gene?

A

STK-11

56
Q

What organs are in the Intraperitoneal space?

A 
1st part of the Duodenum
Small Intestine
Transverse Colon
Sigmoid Colon
Rectum
57
Q

What organs are in the Retroperitoneal space?

A

Distal Duodenum
Ascending Colon
Descending Colon
Anal Canal

58
Q

What are some of the steps for resuscitation of a patient with an Acute Upper GI Bleed?

A
  • Atleast two large bore cannula insertion (16-18G)
  • FBC, U&Es, Clotting, Cross-matching
  • Arterial / Venous blood gas sampling
  • Notify duty endoscopist within 1 hour
  • Place patient on nil by mouth
  • Implement haemorrhage protocol
59
Q

What is Angiodysplasia? How is it treated?

A

Small vascular malformations located in submucosa and mucosa of the lower GI tract. Treated with Adrenaline and APC

60
Q

CA19-9 is a marker for which disease?

A

Pancreatic Cancer

61
Q

CEA is a marker for which disease?

A

Colorectal Cancer

62
Q

AFP is a marker for which disease?

A

Hepatocellular Carcinoma

63
Q

Bowel obstruction is more common in colorectal cancer of Ascending or Descending Bowel?

A

Descending Bowel

64
Q

Ischaemic Colitis is common in which part of the GI tract? Why?

A

Splenic flexure (1st) and Retrosigmoidal area (2nd) due to watershed areas

65
Q

What is “Apple Coring” as seen on a Barium enema?

A

A sign of lumenal narrowing, commonly in Colon cancer of the Descending Colon

66
Q

What is the difference between the outer layers of Intraperitoneal and Retroperitoneal organs?

A

Intraperitoneal organs - Serosa

Retroperitoneal organs - Adventitia

67
Q

What is the mechanism of action of Proton Pump Inhibitors?

A

H+/K+/ATPase Inhibitor

68
Q

CA125 is a marker for which disease?

A

Ovarian, Endometrial, Fallopian tube Cancer

69
Q

A patient with a large rectal bleed and is haemodynamically unstable, has a diagnosis of what until proven otherwise?

A

Upper GI Bleed

70
Q

What is the first-line investigation for Ischaemic Bowel Disease?

A

Lactate

Medicine, Year 3, GI and Surgery (12 decks)

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