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Met3 > Gastroenterology; Upper GI; GI Bleeding > Flashcards

Gastroenterology; Upper GI; GI Bleeding Flashcards

1
Q

Which anatomical point distinguishes between an upper and lower GI bleeding? [1]

A

Ligament of Treitz:
- Proximal: upper GI
- Distal: lower GI

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2
Q

How do you distinguish clinically between upper and lower GI bleed? [3]

A

Upper:
- Haematemesis (vomiting blood)
- Maleana
- Haematochexia: only if LARGE upper bleed (fresh blood PR)

Lower:
- Maleana
- Haematochexia

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3
Q

State the causes of upper GI bleeds [5]

A

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%

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4
Q

State the causes of lower GI bleeds [5]

A

Diverticular disease (30%)
* Haemorrhoids (14%)
* Mesenteric Ischaemia (12%)
* Colitis (9%)
* Cancer (6%)
* Rectal ulcers (6%)
* Angiodysplasia (3%)
* Radiation (3%)
* Drugs
* Other

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5
Q

What is this common cause of upper GI bleeding? [1]

A

Peptic ulcer disease

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6
Q

Risk factors for PUD? [4]

A

H. pylori
NSAIDs
Smoking
Alcohol

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7
Q

Why does PUD cause bleeding? [1]

A

Erodes into an artery

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8
Q

What is this cause of upper GI bleeding? [1]

A

Oesophagitis

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9
Q

What is this cause of upper GI bleeding? [1]

A

Gastritis

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10
Q

What is this cause of upper GI bleeding? [1]

A

Duodenitis

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11
Q

State 4 causes of gastritis / duodenitis [4]

A

H. pylori
NSAIDS
Smoking
Alcohol

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12
Q

Which of the following blood markers classically rises with an upper gastrointestinal bleed?

Urea
GGT
Potassium
Haemoglobin

A

Which of the following blood markers classically rises with an upper gastrointestinal bleed?

Urea
GGT
Potassium
Haemoglobin

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13
Q

What is it image depicted of upper GI bleeding? [1]

A

Gastric / oesophageal varices

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14
Q

What is the most common cause of gastric / oesophageal varices in the UK? [1]

A

Portal HTN: due to liver cirrhosis or venous occlusion

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15
Q

What is the most common cause of portal HTN worldwide? [1]

A

Schistomiasis

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16
Q

What is a mallory weiss tear? [1]

Describe typical presentation [1]

A

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

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17
Q

Describe pathophysiology is diverticular disease causing lower GI bleeding? [1]

How does diverticular disease lead to lower GI bleeding? [1]

A

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

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18
Q

What is the difference between diverticulosis and diverticulitis? [2]

A

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.

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19
Q

What are causes of diverticular disease? [6]

A
  • Constipation
  • Genetics
  • Obesity
  • NSAIDs
  • Low fibre diet
  • Muscle spasm
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20
Q

The NICE clinical knowledge summaries (updated January 2021) suggest management of uncomplicated diverticulitis in primary care with.. [4]

A

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
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21
Q

How do you manage d

A

Management is with increased fibre in the diet and bulk-forming laxatives (e.g., ispaghula husk). Stimulant laxatives (e.g., Senna) should be avoided

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22
Q

Describe the presentation of diverticulosis [3]

A

Diverticulosis may cause lower left abdominal pain that relieved by defecation, constipation or rectal bleeding

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23
Q

State 5 causes of haemorrhoids [5]

A
  • Straining (in bowel movement)
  • Sitting for long periods
  • Chronic diarrhoea or constipation
  • Overweight / obese
  • Pregnancy
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24
Q

Which line determines if a haemorrhoid is internal / external? [1]

A

External:
originate below the dentate line
prone to thrombosis, may be painful

Internal:
originate above the dentate line
do not generally cause pain

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25
Q

Describe how colonic cancer develops [3]

A
  1. polyps;
  2. larger polyp (severe dysplasia)
  3. adenocarcinoma
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26
Q

State 4 reasons that cause colitis which in turn causes lower GI bleeding [4]

A

Ishcaemic colitis: in distal transverse colon / descending colons - position as watershed area between SMA & IMA can lead to bleeding

IBD

Infection

NSAIDs

27
Q

When taking a history for upper GI bleed, what should you investigate? [3]

A

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)

28
Q

Describe how you would assess if a patient requires immediate resuscitation? (A-E) [5]

A

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

29
Q

What are the different classes of blood loss? (% and volume lost?) [4]

A

Class 1:
- 10-15%
- 750mls

Class 2:
- 15-30%
- 1.5L

Class 3:
- 30-40%
- 2L

Class 4:
- >40%
- 3L

30
Q

Describe the symptoms that classify each class of shock with regards to blood loss? [4]

A

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

31
Q

For GI bleed, how many cannuale are required in veins? [1]

A

2 wide bore cannulae in large veins

32
Q

Which cannulae are wide bore? [4]

A
  • 14G (300ml/min)
  • 16G (150 ml/min)
  • 17G
  • 18G (75ml/min)
33
Q

What are possible complications of massive blood transfusion [5]

A

- 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

34
Q

Which blood tests would you suggest for investigating upper GI bleed? [7]

A
  • 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
35
Q

Explain how urea levels changing can indicate a GI bleed [1]

A

Urea increasing: indicates blood in GI tract - proteins converted to urea

36
Q

How do you optimise clotting:

  • What levels should: platelets [1] and INR [1] be above/below? [2]
  • Drug management? [2]
A

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

37
Q

What drugs might be prescribed if have an upper GI bleed? [2]

A

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.

38
Q

Specific treatment for variceal bleeding? [2]

A

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

39
Q

Name the scoring system used to determine if risk of re-bleeding [1]
Which scores result in outpatient endoscopy [1]

A

Blatchford score
< 2: low risk - outpatient endoscopy
> 6: endoscopic Rx

40
Q

Name another score (other than Blatchford score) for upper GI blleds [1]
What is important to note about this score [1]

A

Rockall score: needs endoscopic diagnosis to calculate full score

41
Q

Describe management of high risk, actively bleeding ulcer [4]

A

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}}

42
Q

What does this image depict of treatment of variceal bleeding? [1]

A

Adrenaline administered; causes vasoconstriction (pale area)

43
Q

What GI bleed treatment is depicted? [1]

A

Clip adminisitered

44
Q

What therapy does this image depict for ulcer GI bleed treatment? [1]

A

Diathermy

45
Q

Describe the endoscopic management of varices [3]

A

Band ligation

Injection sclerotherapy (glue)

Sengestaken blakemore tube: compresses varices

46
Q

What is the name for this oesphageal varice treatment? [1]

A

Banding

47
Q

Name this Tx of endoscopic variceal bleeding

A

Injection sclerotherapy

48
Q

What is this endoscopic tx for oesophageal variceal bleeding? [1]
Explain how it works [2]

A

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}

49
Q

Explain post-endoscopical / medical therapy for ulcers: [3]

A

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

50
Q

Describe post-endoscopic treatment of varices [4]

A
  • 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
51
Q

When would you use interventional radiology or red cell scanning with GI bleeds? [2]

Describe the procedures [2]

A

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

52
Q

What is the most common cause of small bowel bleeding? [1]

A

Angiodysplasia: abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract.

53
Q

How do you diagnose and treat small bowel bleeding? [5]

A

Video capsule endoscopy (diagnosis): pill w/ camera
Balloon enteroscopy
CT angiogram & angiography
Interventional angiography
Red cell scan

54
Q

Describe management plan for upper bleeds [6]

A

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)

55
Q

A patient has suspected bleeding varices. What two drugs should you prescribe? [2]
Is this before or after endoscopy? [1]

A

Terlipressin & Antibiotics (Ceftriaxone)
BEFORE endoscopy

56
Q

What is the management for oesophageal varices if terlipressin and antibiotics does not work? [1]

A

Sengstaken-Blakemore tube if uncontrolled haemorrhage

57
Q

What is the management if Sengstaken-Blakemore tube cannot manage uncontrolled haemorrhage of variceal haem.? [1]

A

Transjugular Intrahepatic Portosystemic Shunt (TIPSS):
connects the hepatic vein to the portal vein

58
Q

A patient has achalasia. The first-line treatment for patients who are young with no comorbidities is []

A

A patient has achalasia. The first-line treatment for patients who are young with no comorbidities is pneumatic dilation

59
Q

Which part of the body is diverticular disease most likely [95%] to occur? [1]

A

Sigmoid colon

60
Q

Why are posterior duodenal ulcers high risk of excess bleeding? [1]

A

Located next to gastroduodeal artery

61
Q

Which drug classes are a risk factor for upper GI bleeds? [5]

A

NSAIDs
Aspirin
Steroids
Thrombolytics
Anticoagulants

62
Q

State 4 complications of diverticular disease [4]

A

Perforations: leading to peritonitis & shock
Haemorrhage: sudden and painless
Fistulae
Abscesses: w/ swinging fever, leuocytosis and localising signs

63
Q

Which blood vessel is most at risk of a duodenal ulcer? [1]

A

Gastroduodenal

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