Gastrointestinal bleeding Flashcards
An upper GI bleed referes to bleeding from which locations?
Oesophagus, stomach or proximal duodenum
Proximal to ligament of treitz
List the 3 key symptoms of an upper GI bleed
- Haematemesis
- Melaena
- Haematochezia
List 4 oesophageal causes of a UGIB
- Varices
- Neoplasm
- Oesophagitis
- Ulcer
- Mallory Weis tear
List 4 gastric causes of a UGIB
- Gastric Ulcer
- Neoplasm
- Gastritis
- Varices
- Dieulafoy’s lesions (large tortuous arteriole)
- Angiodysplasia
List 4 duodenal causes of a UGIB
- Duodenal ulcer
- Neoplasm
- Duodenitis
- Vascular malformations
- Aortoenteric fistulae
Which scoring system is used to predict the need for admission and timing of endoscopic intervention
Glasgow-Blatchford Score
Which scoring system is used to predict risk of re-bleeding and mortality
Rockall Score
Can be calculated pre and post endoscopy
What score should be used at 1st assessment to risk stratify
Blatchford
What is the Initial management of a Non-variceal bleed
- ABCDE
- Assess degree of shock
Management of a Non-variceal bleed?
- Fluid resuscitation
- Blood transfusion
- Vit K or Octaplex
- PPI, erythromycin, Tranexamic acid
- Endoscopy
Within what time frame is an endoscopy reccomended for UGIB?
Why?
Early endoscopy (within 24hrs)
For prompt diagnosis, risk stratification and haemostasis therapy
Endoscopic therapies for UGIB?
Aims to achieved Haemostasis by:
- Adrenaline injection + 2nd modality
- Thermal coagulation
- Mechanical–endoclips
- Hemospray
- (Glue/thrombin for varices)
What is the Forrest Classification?
ASK RISH
What is the only definitive way to treat oesophageal varicies?
TIPS - Transjugular intrahepatic portosystemic shunt
In what condition is Variceal bleeds most common?
Cirrhosis (50% of patients)
- 30-40% in compensated disease
- 85% in decompensated
Initial management of a Variceal bleed?
- ABCDE
- Anaesthetist – consider intubation
- DOCC / ITU
- Gastro SpR/Cons on call (out-of hours)
Management of a variceal bleed?
(Hint: VARICEAL B)
- Vasoconstrictor therapy
- Antibiotics
- Resuscitation
- ICU level care
- Endoscopy
- ALternative therapies
- Beta blockade
What is the purpose of Vasoconstrictor therapy in management of a VB?
List an example of a medication used
Reduce splanchnic blood flow
eg. Terlipressin, Octreotide
Why is it important to administer antibiotics in a VB?
List an example
Bacterial translocation occurs in 2/3 of cases → prophylactic antibiotics significantly reduces mortality
Broad spectrum: Tazocin
How soon should an endoscopy be performed following admission of a VB
What endoscopic therapies may aid treatment?
Urgent ASAP after resus! (Intubation often needed)
Therapy
- Variceal band ligation
- Tissue glue cyanoacrylate – gastric varix (we use thrombin)
If an endoscopy cannot be performed in a VB, list 2 alternative / rescue therapies
CHECK THIS
- TIPS (Transjugular intrahepatic portosystemic shunt) → ↓ portal pressure and complications related to portal HTN
- Sengstaken-Blakemore Tube
What is the purpose of Beta blockade in the management of VB?
List an example of a medication used
Reduces risk of recurrent VB
- ↓ splanchnic vasoconstriction
- ↓ CO
Non-selective β-blocker eg. propanolol or carvedilol
Post endoscopic management of a non-variceal blead?
- For low risk ulcers – fed promptly, start oral PPI
- Forrest classification and risk of re-bleeding
- If endoscopic therapy – 72 hour PPI infusion
- If DU – give empirical HP eradication therapy
- Discharge on PPI (when Hb >8) and advise against NSAID use
Post endoscopic management of a variceal blead?
- Continue antibiotics 5/7
- Wean terlipressin early after successful banding
- Beta blockade (secondary prophylaxis) in combo with
- Variceal banding programme - repeat OGD at 2-4wks until eradication achieved
Management in case of re-bleeds?
Repeat OGD +/- therapeutics
Management If bleeding is uncontrolled?
- Interventional radiology – CT angiogram +/- embolisation vs. TIPSS
- Surgeons
- Under running with or without pyloro-plasty
- Local excision or partial gastrectomy
A lower GI bleed referes to bleeding from which locations?
colon and rectum
Is a patient with severe haematochezia more likley to be an UGIB or LGIB
UGIB - 15% of UGIB present as LGIB
List 4 painLESS causes of a LGIB, highlight the most common
- Diverticular*
- Aortoenteric fistula*
- Malignancy
- Angiodysplasia–Heyde’s syndrome
- Haemorrhoidal
- Post-polypectomy
List 4 painFULL causes of a LGIB
- Colitis (UC, Crohns, infectious)
- Ischaemic colitis
- Massive UGIB*
Initial management of a LGIB
- ABCDE
- Stabilise and resuscitate (fluids/blood products)
These are usually self-limiting
List 4 investigations for a LGIB
- OGD
- CT angiogram
- Flexible sigmoidoscopy vs colonoscopy
List 3 Therpies for a LGIB that is not self-limiting
- Submucosal injections of adrenaline
- Clip / heat
- APC
Performed during a Flexible sigmoidoscopy or colonoscopy
Under what circumstances would a LGIB require surgery?
Massive haemorrhage + haemodynamic instability → surgery
