CPC 7 haematemesis and melaena Flashcards
Causes of upper GI bleeding by anatomical areas.
Oesophagus
Stomach
Duodenum
Causes of bleeding in the oesophagus
Oesophagitis
Mallory-Weiss tear
Varices
What causes varices?
Portal hypertension
What are the classes of causes of portal hypertension?
Pre-hepatic, intra-hepatic and post-hepatic.
Pre-hepatic causes of portal hypertension
Portal vein thrombosis
Intra-hepatic causes of portal hypertension
Cirrhosis
Schistosomiasis
Sarcoidosis
Congenital hepatic fibrosis.
Definition of liver cirrhosis
A diffuse process characterized by fibrosis and conversion of normal architecture into structurally abnormal nodules.
Causes of liver cirrhosis
Alcoholic Viral Autoimmune (5%) Metabolic NAFLD
Post-hepatic causes of portal hypertension
o Venous outflow obstruction
o Budd-Chiari syndrome
o Veno-occlusive disease.
Complication of portal hypertension.
As well as varices, o Splenomegaly o Ascites o Spontaneous bacterial peritonitis o Encephalopathy.
Treatment for portal hypertension leading to oesophageal varices and haematemesis.
A transjugular intrahepatic portosystemic shunt, which connects the portal vein to a branch of the abdominal aorta, providing a bypass of the liver.
Where do varices occur in portal hypertension.
Usually O-G junction also retroperitoneal, rectal and caput medusae.
Gastric causes of upper GI bleeding.
Peptic ulcer Gastritis PHG (portal hypertensive gastropathy). Malignancy Vascular ectasia.
Risk factors for peptic ulcers
Easy to remember - 4. • H. pylori • Smoking • Drugs – including NSAIDs, aspirin, cocain and corticosteroids. • Stress
Also 5 more: • COPD • Alcoholic cirrhosis • Endocrine cell hyperplasia • Zollinger-Ellison Syndrome (PUD of stomach, duodenum and jejunum) • Viral infection.
Ways to diagnose H pylori infection. Direct and indirect, invasive and non-invasive.
- Direct, invasive – Histology, culture
- Direct, non-invasive - Faecal antigen
- Indirect, invasive – CLO test
- Indirect, non-invasive – Urea breath test, serology
What is gastropathy?
Gastropathy is mucosal injury to the stomach without significant inflammation, commonly secondary to endogenous or exogenous irritants.
Symptoms of gastropathy
- None
- Pain
- Nausea and vomiting
- Acute GI bleed
- Acute gastric ulcer
- Massive haematemesis.
Causes of gastropathy
• H. pylori is common cause. Also autoimmune gastritis, commonly causes diffuse atrophic gastritis.
Common risk factors of gastropathy.
Involves NSAIDs, alcohol, smoking, chemotherapy, bile reflux uraemia and etc. Occurs in 25% of those taking aspirin for rheumatoid arthritis.
Gastric cancer - epidemiology
• More common in Japan. 90% are adenocarcinoma. Others include malt lymphoma, neuro-endocrine tumours and GI stromal tumours.
Risk factors for gastric cancer
Genetic factors, being in lower socioeconomic groups, H. pylori, diet, smoking, chronic gastritis.
Genetic factors predisposing to gastric adenocarcinomas
o Lynch syndrome
o Hereditary diffuse gastric cancer (defect in e-cadherin)
o Familial adenomatous polyposis.
Growth patterns of gastric adenocarcinomas.
Intestinal type
Diffuse type
Epidemiology of intestinal type of gastric adenocarcinoma.
Predominates in at risk areas, presentation usually around 55, male:female = 2:1
Pathology of intestinal type of gastric adenocarcinoma.
Has precursor lesions, mostly exophytic, ulcerated or excavated.
Haematological spread to liver, lungs and nodes, esp Virchow’s node.
Epidemiology of diffuse type of gastric adenocarcinoma.
Uniform geographical distribution, equal numbers of males and females.
Pathology of diffuse type of gastric adenocarcinoma.
No precursor lesions. Flat, linitus plastica
transperitoneal spread (Krukenberg tumour).
Symptoms of gastric adenocarcinoma
Vague, generally similar to gastritis.
Prognosis of gastric adenocarcinoma.
Survival sharply declines with advancement of cancer, even after metastasis.
Causes of haematemesis and melaena presentations:
More than 20%: peptic ulcers, oesophagitis, gastritis.
More than 10%: duodenitis, varices.
Less than 10%: PHG, malignancy, Mallory-Weiss tear, vascular ectasia.
Intrinsic clotting cascade pathway
XII, XI, IX, X (VIII), prothrombin (V), Thrombin, fibrinogen.
Extrinsic clotting cascade pathway
Injury, tissue factor, VIIa + TF, X, thrombin, fibrinogen.
APTT
involves the intrinsic pathway and time taken to clot
PT
involves the extrinsic pathway and time taken to clot.
Definition of portal hypertension
Sustained increase in portal venous pressure, caused by obstruction to blood flow somewhere in the portal circuit with complications arising from increased pressure and dilatation of the venous bed behind the obstruction
Clinical features of multiple endocrine neoplasia type 1
parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
pituitary (70%)
pancreas (50%, e.g. Insulinoma, gastrinoma)
also: adrenal and thyroid
Zollinger-Ellison syndrome
Characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas. Around 30% occur as part of MEN type I syndrome.
Features of Zollinger-Ellison syndrome
multiple gastroduodenal ulcers
diarrhoea
malabsorption
