Gastroenterology (Bleeds, Constipation, Diarrhoea and Dysphagia) Flashcards
causes of upper GI bleeds: Variceal vs Non-variceal
Variceal
- oseophageal varices secondary to portal hypertension in liver cirrhosis
Non-variceal
- peptic ulcer (most common)
- Mallory weis tear
- Stomach cancers
presentation of acute upper GI bleed
- Haematemesis – vomiting blood
- This can be bright red or described as ‘coffee grounds’
- Melaena – describes the passage of digested blood as black, tarry stools
- Nausea and vomiting – blood in the GI tract is pro-emetic
- Increased urea levels:
->Helps distinguish lower GI and upper GI bleeds as the digestion of blood increases urea - Signs and symptoms of associated diagnoses (e.g. stigmata of liver disease)
- Signs of decompensation – tachycardia or hypotension
- Heart rate is a better measure as blood pressure initially can remain normal
risk assessment scores for upper GI bleed
The Blatchford score – done at first assessment
The full Rockall score – done after endoscopy
the blatchford score
Done at first assessment
It estimates the risk of the patient having an upper GI bleed and therefore if they can be management as an outpatient.
- A score above 0 indicates a high risk for an upper GI bleed.
- The NICE guidelines (updated 2016) suggest considering early discharge in patients with a score of 0.
The easiest way to calculate the score is using an online calculator. It takes into account:
- Haemoglobin (falls in upper GI bleeding)
- Urea (rises in upper GI bleeding)
- Systolic blood pressure
- Heart rate
- Presence of melaena (black, tarry stools)
- Syncope (loss of consciousness)
- Liver disease
- Heart failure
Rockall score
Done after endoscopy
Estimates the risk of rebleeding and mortality.
It takes into account:
- Age
- Features of shock (e.g., tachycardia or hypotension)
- Co-morbidities
- Cause of bleeding (e.g., Mallory-Weiss tear or malignancy)
- Endoscopic findings of recent bleeding (e.g., clots and visible bleeding vessels)
emergency management of upper GI bleed
The initial management can be remembered with the ABATED mnemonic:
- A – ABCDE approach to immediate resuscitation
- B – Bloods
- A – Access (ideally 2 x large bore cannula)
- T – Transfusions are required
- E – Endoscopy (within 24 hours)
- D – Drugs (stop anticoagulants and NSAIDs)
blood tests for Upper GI bleed
- Full blood count – may identify anaemia or thrombocytopenia
- Crossmatching – in case blood products are necessary
- Coagulation profile – to identify coagulopathy
- Liver function tests – to identify underlying liver disease
- Urea and electrolytes – urea is elevated in UGIB
blood transfusion for upper GI bleed
- Blood, platelets and fresh frozen plasma are given to patients with massive bleeding
- Transfusing more blood than necessary can be harmful
- Platelets are given in active bleeding plus thrombocytopenia (platelet count less than 50)
- Prothrombin complex concentrate can be given to patients taking warfarin that are actively bleeding
management of Upper GI bleed caused by Variceal bleeding
Before OGD
- Terlipressin
- Broad spec antibiotics
During endoscopy
- Variceal band ligation
management of Upper GI bleed caused by non- variceal bleeding
do not give PPI before endoscopy
OGD
- can be treated with adrenaline or clips or thermal coagulation
Lower gastrointestinal bleeding (LGIB)
describes bleeding occurring distal to the ileocaecal valve (i.e. the colon, rectum, and anus). It is common, and most cases are due to benign causes, however, there are many other possible causes, including malignancy.
presentation of lower GI bleed
- bright or dark red blood
- blood generally accelerates intestinal transit time, meaning it is expelled sooner and before enzymatic digestion
investigations for lower GI bleed
Full blood count (FBC):
- May show anaemia
- Increased white cell counts suggest infection
- May show thrombocytopenia which can predispose to bleeding
Clotting studies:
- May show clotting abnormalities such as increased INR, PT, or APTT
Group and save:
- Determines patient blood group and screens for atypical antibodies
- A crossmatch may be considered which is where red cell products are provided to the patient
Iron studies:
- May show iron-deficiency anaemia
Urea and electrolytes:
- May show elevated urea suggesting a UGIB
Liver function tests:
- May be deranged suggesting liver cirrhosis
- Low albumin may occur due to liver cirrhosis or protein-losing enteropathy
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR):
- May be elevated in inflammatory bowel disease
Faecal calprotectin:
- Considered if inflammatory bowel disease is suspected
Stool culture tests:
- If infective causes are suspected
Testing for sexually-transmitted infections:
- May be considered
Lower GI bleeds: Haemodynamically unstable patients
Patients with haemodynamic instability (e.g. those with hypotension) should first be resuscitated. Investigations may then include:
Urgent CT angiogram (CTA) – before endoscopy
- This can localise the bleeding site and therapies to stop bleeding (e.g. embolisation) can be performed to stabilise the patient
Upper GI endoscopy:
- May be considered if the CTA cannot localise the bleed site
Emergency laparotomy:
- If a CTA and endoscopy fail to locate the bleeding site
Haemodynamically stable patients: Lower GI bleed
Blood transfusions may initially be considered. Following this, investigations may involve:
Colonoscopy:
* May identify masses and allows for therapeutic intervention
Upper GI endoscopy:
* If colonoscopy does not identify any causes
differentials for lower GI bleed
- Haemorrhoids
- Anal fissures
- Diverticular disease
- Crohns disease
- UC
- Lower GI cancer
- Infectious gastroeteritis
constipation definitions
Constipation describes problems with defecation due to hard stools, difficulty passing them, or the sensation of incomplete emptying or anorectal blockage. Chronic constipation is where these symptoms are present for at least 3 months.
Faecal impaction (or loading) describes the retention of faeces to the point where spontaneous passage is unlikely.
Overflow faecal incontinence (also known as encopresis or bypass soiling) describes leakage of liquid stool around impacted faeces.
Constipation can be divided into:
- Primary (or idiopathic) – such as irritable bowel syndrome-C (IBS-C)
- Secondary (or organic) – constipation caused by an underlying cause such as a drug or medical condition
secondary causes of constipation
Drugs
- Opioids
- Anticholinergics e.g. tricyclic antidepressants
- CCBs
- Antipsychotics
Structural disorders
- Anal fissures
- HAemorrhoids
- Colonic stircutre
- IBD
- Obstruction
- Mass
- Diverticulosis
Endocrine
- Hypothyroidism
- Hypercalcaemia and hyperparathryoidism
- DM
- Hypokalameia
Neuro
- Stroke
- MS
- Parkinsons
- Spinal cord injury
- Brain tumour
presentation of constipation
- Bowel movements <3 times a week may be considered constipation
- Constipation is generally considered when stools are passed less frequently than what is normal for the patient
- There may be additional symptoms such as abdominal pain, discomfort, or bloating
Elderly people and constipation
Elderly patients may have non-specific symptoms:
- Confusion or delirium
- Overflow diarrhoea
- Nausea, vomiting, or loss of appetite
- Urinary retention
red flags for constipation
- Age >50 years
- Weight loss
- Associated symptoms such as rectal bleeding, tenesmus, or discharge
- Blood in the stool
- Recent onset of symptoms
- Symptoms suggesting obstruction
- Rectal prolapse
- Change in stool calibre
Clostridioides difficile
(C. difficile) is a Gram-positive anaerobic rod spread by bacterial spores found in faeces.
- It is known for causing inflammation of the colon.
- Surfaces may be contaminated with spores and spread via the hands of healthcare workers.
