Gastroenterology; Upper GI; GI Bleeding Flashcards
Which anatomical point distinguishes between an upper and lower GI bleeding? [1]
Ligament of Treitz:
- Proximal: upper GI
- Distal: lower GI
How do you distinguish clinically between upper and lower GI bleed? [3]
Upper:
- Haematemesis (vomiting blood)
- Maleana
- Haematochexia: only if LARGE upper bleed (fresh blood PR)
Lower:
- Maleana
- Haematochexia
State the causes of upper GI bleeds [5]
Peptic Ulcer Disease – 44%
Oesophagitis - 28%
Gastritis/Erosions – 26%
Erosive Duodenitis – 15%
Varices – 13%
Portal Hypertensive gastropathy – 7&
Malignancy - 5%
Mallory Weiss Tear – 5%
Vascular Malformation – 3%
State the causes of lower GI bleeds [5]
Diverticular disease (30%)
* Haemorrhoids (14%)
* Mesenteric Ischaemia (12%)
* Colitis (9%)
* Cancer (6%)
* Rectal ulcers (6%)
* Angiodysplasia (3%)
* Radiation (3%)
* Drugs
* Other
What is this common cause of upper GI bleeding? [1]
Peptic ulcer disease
Risk factors for PUD? [4]
H. pylori
NSAIDs
Smoking
Alcohol
Why does PUD cause bleeding? [1]
Erodes into an artery
What is this cause of upper GI bleeding? [1]
Oesophagitis
What is this cause of upper GI bleeding? [1]
Gastritis
What is this cause of upper GI bleeding? [1]
Duodenitis
State 4 causes of gastritis / duodenitis [4]
H. pylori
NSAIDS
Smoking
Alcohol
Which of the following blood markers classically rises with an upper gastrointestinal bleed?
Urea
GGT
Potassium
Haemoglobin
Which of the following blood markers classically rises with an upper gastrointestinal bleed?
Urea
GGT
Potassium
Haemoglobin
What is it image depicted of upper GI bleeding? [1]
Gastric / oesophageal varices
What is the most common cause of gastric / oesophageal varices in the UK? [1]
Portal HTN: due to liver cirrhosis or venous occlusion
What is the most common cause of portal HTN worldwide? [1]
Schistomiasis
What is a mallory weiss tear? [1]
Describe typical presentation [1]
Forceful vomiting / retching causing a mucosal tear in the oesophagus causing subsequent bleeding
First bout of vomiting has no bleeding (prior to tear)
Second + bout of vomiting has bleeding
Describe pathophysiology is diverticular disease causing lower GI bleeding? [1]
How does diverticular disease lead to lower GI bleeding? [1]
Diverticular disease:
- a condition where small pouches (called diverticula) form in the lining of your bowel and push out through your bowel wall due to high intra-luminal pressure
-
Diverticulae lie adjacent to mesenteric blood flow and because they cause decreased thickness of colonic thickness; increases chance of bleeding
What is the difference between diverticulosis and diverticulitis? [2]
Diverticulosis refers to the presence of diverticula, without inflammation or infection. Diverticulosis may be referred to as diverticular disease when patients experience symptoms.
Diverticulitis refers to inflammation and infection of diverticula.
What are causes of diverticular disease? [6]
- Constipation
- Genetics
- Obesity
- NSAIDs
- Low fibre diet
- Muscle spasm
The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with.. [4]
The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with:
- Oral co-amoxiclav (at least 5 days)
- Analgesia (avoiding NSAIDs and opiates, if possible)
- Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
- Follow-up within 2 days to review symptoms
How do you manage d
Management is with increased fibre in the diet and bulk-forming laxatives (e.g., ispaghula husk). Stimulant laxatives (e.g., Senna) should be avoided
Describe the presentation of diverticulosis [3]
Diverticulosis may cause lower left abdominal pain that relieved by defecation, constipation or rectal bleeding
State 5 causes of haemorrhoids [5]
- Straining (in bowel movement)
- Sitting for long periods
- Chronic diarrhoea or constipation
- Overweight / obese
- Pregnancy
Which line determines if a haemorrhoid is internal / external? [1]
External:
originate below the dentate line
prone to thrombosis, may be painful
Internal:
originate above the dentate line
do not generally cause pain
Describe how colonic cancer develops [3]
- polyps;
- larger polyp (severe dysplasia)
- adenocarcinoma
State 4 reasons that cause colitis which in turn causes lower GI bleeding [4]
Ishcaemic colitis: in distal transverse colon / descending colons - position as watershed area between SMA & IMA can lead to bleeding
IBD
Infection
NSAIDs
When taking a history for upper GI bleed, what should you investigate? [3]
History:
- Determine if upper or lower GI bleed: haematemesis?
Systemic symptoms of blood loss?
- Dizzyness
- Palpitations
- Chest pain
Risk factors?
- Drugs
- Chronic liver disease (portal HTN?); IHD (anticoagulants); CKD (poorer prognosis)
Describe how you would assess if a patient requires immediate resuscitation? (A-E) [5]
Airway: is blood going to interfere airway - need intubation?
Breathing: RR; O2 saturations, ABG & CXR
Circulation: IV access & give fluids; blood produces; HR & BP monitoring
Disability: ACVPU
Else: Abdominal exam; rectal exam
What are the different classes of blood loss? (% and volume lost?) [4]
Class 1:
- 10-15%
- 750mls
Class 2:
- 15-30%
- 1.5L
Class 3:
- 30-40%
- 2L
Class 4:
- >40%
- 3L
Describe the symptoms that classify each class of shock with regards to blood loss? [4]
Class 1:
- no clinical signs
Class 2:
- postural hypotension
- generalised vasoconstriction
Class 3:
- Hypotension
- Tachycardia over 120
- Tachyopnea
Class 4:
- Marked hypotension
- Marked tachycardia
- marked tachyopnea
- Comatose
For GI bleed, how many cannuale are required in veins? [1]
2 wide bore cannulae in large veins
Which cannulae are wide bore? [4]
- 14G (300ml/min)
- 16G (150 ml/min)
- 17G
- 18G (75ml/min)
What are possible complications of massive blood transfusion [5]
- Fluid overload
- Electrolyte / Acid-Base disturbance
- Transfusing products devoid of clotting factors (consider giving additional platelets)
- Hypothermia (blood transfused is cold)
Repeated transfusions:
- Iron overload
Which blood tests would you suggest for investigating upper GI bleed? [7]
- Blood gas: contains Hb and lactate levels
- FBC: Hb and clotting levels
- U&E: kidney function
- LFTs
- Coagulation screen
- Cross match (to find a compatible samples for transfusion)
OR - Group and save (instruct transfusion lab to find blood group of patient and save serum of sample sent for later cross match
Explain how urea levels changing can indicate a GI bleed [1]
Urea increasing: indicates blood in GI tract - proteins converted to urea
How do you optimise clotting:
- What levels should: platelets [1] and INR [1] be above/below? [2]
- Drug management? [2]
Platelets: > 50
INR: < 1.5
Do not give any anti-coagulants the Ptx may be on (warfarin, clopidogrel, aspirin, DOAC)
Reverse warfarin with vitamin K
What drugs might be prescribed if have an upper GI bleed? [2]
PPI:
- Decrease lesions identified at endoscopy level; but no difference in transfusion, surgery or mortality
- NICE does not rec. PPI before endoscopy
Tranexamic acid?
- improves clotting in area of GI bleeding, but may improve clotting with poor vascular blood flow & cause CAD.
Specific treatment for variceal bleeding? [2]
Terlipressin:
- causes mesenteric and splachnic vasoconstriction
- contraindicated in IHD
Antibiotics:
- cephalosporin; quinolone; augmentin
- reduces liklihood of sepsis, which decreases portal pressure
- treat chest infection if aspiratio has occurred.
NOTE: Propanolol is prophylaxis
Name the scoring system used to determine if risk of re-bleeding [1]
Which scores result in outpatient endoscopy [1]
Blatchford score
< 2: low risk - outpatient endoscopy
> 6: endoscopic Rx
Name another score (other than Blatchford score) for upper GI blleds [1]
What is important to note about this score [1]
Rockall score: needs endoscopic diagnosis to calculate full score
Describe management of high risk, actively bleeding ulcer [4]
Adrenaline:
- vasoconstriction
- causes local tamponade of blood vessels
Clip: closes bleeding
Diathermy: (therapeutic treatment that uses electric currents (radio and sound waves) to generate heat in layers of your skin below the surface)
Haemospray: powder in endoscope; promotes clotting}}
What does this image depict of treatment of variceal bleeding? [1]
Adrenaline administered; causes vasoconstriction (pale area)
What GI bleed treatment is depicted? [1]
Clip adminisitered
What therapy does this image depict for ulcer GI bleed treatment? [1]
Diathermy
Describe the endoscopic management of varices [3]
Band ligation
Injection sclerotherapy (glue)
Sengestaken blakemore tube: compresses varices
What is the name for this oesphageal varice treatment? [1]
Banding
Name this Tx of endoscopic variceal bleeding
Injection sclerotherapy
What is this endoscopic tx for oesophageal variceal bleeding? [1]
Explain how it works [2]
Sengstaken-Blakemore Tube [1]
Tube into stomach; inflate balloon; pull up agaisnt fundus of stomach; compresses varices so that blood can’t flow into varices}
Explain post-endoscopical / medical therapy for ulcers: [3]
PPIs:
- allow ulcers to heal
- increase gastric pH; improves clotting ability (low pH activates pepsin which inactivates platelets)
- some patients will need continous infusion for 72hrs
H. pylori eradication (triple therapy: 1xPPI; 2xantibiotics)
Reassess of OGD
Describe post-endoscopic treatment of varices [4]
- Beta blockers (reduce portal pressure: carvedilol; propanolol)
- Sequential banding procedures (close future varices)
- TIPPS: blood from portal vein goes straight from liver into systemic system (reduces pressure)
- Liver transplant
When would you use interventional radiology or red cell scanning with GI bleeds? [2]
Describe the procedures [2]
If endoscopy fails / too unwell to have endoscopy
Interventional radiology:
- CT angiogram: IDs bleeding vessel
- Angiography: embolise the vessel
Surgery:
- If have uncontrolled bleeding
- Failed 2x endoscopic treatment
What is the most common cause of small bowel bleeding? [1]
Angiodysplasia: abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract.
How do you diagnose and treat small bowel bleeding? [5]
Video capsule endoscopy (diagnosis): pill w/ camera
Balloon enteroscopy
CT angiogram & angiography
Interventional angiography
Red cell scan
Describe management plan for upper bleeds [6]
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)
A patient has suspected bleeding varices. What two drugs should you prescribe? [2]
Is this before or after endoscopy? [1]
Terlipressin & Antibiotics (Ceftriaxone)
BEFORE endoscopy
What is the management for oesophageal varices if terlipressin and antibiotics does not work? [1]
Sengstaken-Blakemore tube if uncontrolled haemorrhage
What is the management if Sengstaken-Blakemore tube cannot manage uncontrolled haemorrhage of variceal haem.? [1]
Transjugular Intrahepatic Portosystemic Shunt (TIPSS):
connects the hepatic vein to the portal vein
A patient has achalasia. The first-line treatment for patients who are young with no comorbidities is []
A patient has achalasia. The first-line treatment for patients who are young with no comorbidities is pneumatic dilation
Which part of the body is diverticular disease most likely [95%] to occur? [1]
Sigmoid colon
Why are posterior duodenal ulcers high risk of excess bleeding? [1]
Located next to gastroduodeal artery
Which drug classes are a risk factor for upper GI bleeds? [5]
NSAIDs
Aspirin
Steroids
Thrombolytics
Anticoagulants
State 4 complications of diverticular disease [4]
Perforations: leading to peritonitis & shock
Haemorrhage: sudden and painless
Fistulae
Abscesses: w/ swinging fever, leuocytosis and localising signs
Which blood vessel is most at risk of a duodenal ulcer? [1]
Gastroduodenal
