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Gastroenterology > Gastrointestinal Bleeding > Flashcards

Gastrointestinal Bleeding Flashcards

1
Q

How can GI bleeds be classified?

A
  • upper GI bleeding (proximal to D-J flexure)
    • variceal bleeding
    • non-variceal bleeding
  • lower GI bleeding (distal to DJ flexure)

Upper GI bleeding is 4x more comon than lower GI bleeding, emergency resuscitation is the same for both though

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2
Q

ABATED

How would you manage an acute GI bleed in an emergency setting?

A
  • ABCDE
  • Bloods → FBC / U+Es / LFTs / INR / G+S / Cross match 2u
  • IV Access
  • Transfuse
  • Endoscopy
  • Drugs → stop anticoagulation

Always remember to reassess ABCDE, the Rockall score is used for risk categorisation for upper GI rebleeding + mortality.

Once pt stable, take history, review, document, discuss + handover.

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3
Q

How would you estimate the degree of blood loss with vital signs?

A
  • RR, HR, BP can be used to estimate degree of blood loss/hypovolaemia
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4
Q

What is the 3-fold aim of history and examination for GI bleeding?

A
  1. identify likely source - upper vs lower + potential cause
  2. determine severity of bleeding
  3. identify precipitants (eg. drugs)
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5
Q

What is important to ask in the presenting complain and history of presentic complaint of a GI bleed history?

A
  • duration, frequency, volume (indicate severity)
  • nature of bleeding
    • haemetemesis or melaena
    • PR dark red blood -> colon
    • PR bright red blood -> rectum, anus
    • if PR bleeding, is blood being alone or with bowel opening
    • if with bowel opening, is blood mixed w/ stool (colonic), coating stool (colonic/rectal), in toilet water (anal) or wiping (anal)
  • ask about associated upper/lower GI symptoms
    • abdo pain, dyspepsia
    • lower abdo pain, bowel symptoms (dirrhoea)
    • changes in bowel habit
    • anorexia, weight loss, n+v, bloating, jaundice
  • previous episodes of bleeding and cause
  • nocturnal? - try and SOCRATES the bleed

http://bestpractice.bmj.com/topics/en-gb/456/diagnosis-approach

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6
Q

What is important to ask in the past medical history for GI bleeds?

A
  • history of GI disease - IBD, IBS, malignancy, GORD, PUD, liver disease etc.
  • bleeding disorders - haemophillia
  • other medical conditions
  • surgical history - appendectomy, colectomy, c-section
  • any recent hospital admissions?
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7
Q

What is important in the medication history for GI bleeds?

A
  • anti-platelets or anti-coagulants
  • GI meds - laxatives, loperamide, PPIs, H2 antags, antacids
  • regular medications - NSAIDs, steroids, bisphosphonates
  • contraception - ectopic, pregnancy, miscarriage
  • over the counter drugs
  • allergies or intolerances?
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8
Q

What is important in the social history for GI bleeds?

A
  • alcoholics at risk of liver disease + poss variceal bleeds
  • smokers at risk of PUD
  • travel history / sexual history / physical contact
  • tattoos / piercings / rec drug / iv drug
  • diet (lack of fibre, gluten, fatty foods)
  • living situation
  • activities of daily living
  • occupation

want to rule out infections such as H. Pylori or any hepatitis

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9
Q

Upper GI bleeding refers to bleeding from oesophagus, stomach, duodenum (ie proximal to ligament of treitz). What are the differentials for an upper GI bleed?

A
  • severe oesophagitis
  • mallory-weiss tear
  • oesophageal varices
  • oesophageal cancer
  • gastric ulcer
  • gastric erosions
  • gastric varices
  • gastric cancer
  • duodenal ulcer
  • duodenitis

nb. bleeding from jejunum/ileum is not common

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10
Q

What is haematemesis?

A
  • vomiting of blood
  • can be bright red from fresh bleeding site
  • or coffee-ground appearance if from stomach over longer time
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11
Q

What specific questions would you want to ask a patient with haematemesis?

A
  • appearance of vomit: eg. coffee-ground - peptic ulcer
  • elicit symptoms to see if pt haemodynamically stable
  • retching or nausea - mallory-weiss tear
  • quantity: large amounts + bright red - oesophageal varices
  • pain - peptic ulcer / gastritis / duodenitis
  • alcoholics - varcies / ulcers
  • B-symptoms: anorexia, dysphagia, weight loss - malignancy
  • medications - NSAIDs, warfarin, steroids
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12
Q

What is melaena?

A
  • faecal output from anus following a bleed from upper GI tract
  • stools look black and tarry
  • melaena can occur bc of bleeding anywhere from oesophagus to right sided colon
  • generally bleeding has to be slow enough to allow time for blood to be chemically altered during transit through bowel
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13
Q

What are important questions to ask a patient with melaena?

A
  • is the patient haemodynamically stable?
  • colour of blood - the lighter it is, the more distal
  • if blood is mixed w/ motion or coated or on surface
  • any pain on defacation
  • diarrhoea and constipation
  • abdominal pain - socrates
  • anaemia symptoms
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14
Q

What would examination of a patient with a GI bleed reveal?

A
  • reduced level of consciousness
  • pale and clammy
  • cool peripheries
  • reduced CRT
  • tachycardic + thready pulse
  • hypotensive with narrow pulse pressure
  • tenderness on abdo exam can point to underlying cause
  • stigmata of chronic liver disease (palmar erythema, leukonychia, dupuytrens, shifting dullness/ascites)
  • digitial rectal exam -> melaena, dark red/bright red blood?
  • signs of anaemia
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15
Q

What is meant by occult GI bleeding?

A

Occult gastrointestinal bleeding is defined as gastrointestinal bleeding that is not visible to the patient or physician, resulting in either a positive fecal occult blood test, or iron deficiency anemia with or without a positive fecal occult blood test

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16
Q

What is the Rockall score?

A
  • for risk stratification
  • identified patients at risk of adverse outcome following acute upper GI bleed
  • score <3 carries good prognosis
  • score >8 carries high risk of mortality
17
Q

What is the management of non-varcieal upper GI bleeds?

A
  • emergency resuscitation as already described
  • endoscopy - urgent OGD within 24hrs - diagnostic + therepeautic
    • treatment administered if active bleeding, visible vessel, adherent blood clot
    • treatment options incl adrenaline injection, coagulation or clipping
    • if re-bleeds, then arrange urgent repeat OGD
  • pharmacology:
    • PPI (infusion) - pH >6 stablises clots + reduces risk of re-bleeding following endoscopic haemostasis
    • tanexamic acid (anti fibrinolytic) - maybe of benefit
    • if H pylori positive then for eradication therapy
    • stop NSAIDs/aspirin/clopidogrel/warfarin/steroids if safe to do so
18
Q

What if medical management of a non-varcieal upper GI bleed fails?

A
  • surgery
  • reserved for pts w/ failed med management (ongoing bleeds despite 2x OGD)
  • nature of op depends on cause of bleeding (most commonly performed in context of bleeding peptic ulcer: DU > GU)
  • eg. under-running of ulcer (bleeding DU), wedge excision of bleeding lesion (e.g. GU), partial/total gastectomy (malignancy)
19
Q

In which patients would you expect a variceal bleed?

A
  • suspect if upper GI bleed in pt with history of chronic liver disease/cirrhosis or stigmata on clinical examination
  • patient might have brisk haematemesis
  • liver cirrhosis results in portal hypertension + development of porto-systemic anastamosis (opening or dilatation of pre-existing vascular channels connecting portal and systemic circulations)
  • clotting derangement in those w/ chronic liver disease can worsen bleeding
20
Q

What are the sites of porto-systemic anastamosis?

A
  • oesophagus
  • umbilicus
  • retroperitoneal
  • rectal

varcies can occur here due to their respective portal and systemic circulations anastomosing

21
Q

What is the management of variceal bleeds?

A
  • emergency resus as already described
  • drugs - somatostatin/octreotide, terlipressin, propanolol
  • endoscopy - band ligation, injection sclerotherapy
  • balloon tamponade - sengstaken-blakemore tube (if failed endoscopic management)
  • radiological procedure - if failed medical/endoscopy
    • ​selective catheterisation + embolisation of vessels feeding varices
    • TIPSS procedure: transjugular intrahepatic porto-systemic shunt
  • surgical - surgical porto-systemic shunts, liver transplant
22
Q

What happens in the TIPSS procedure?

A
  • shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding from varices
  • performed if failed medical and endoscopic management
  • can worsen hepatic encephalopathy
23
Q

What is the prognosis of variceal bleed?

A
  • prognosis is closely related to severity of underlying chronic liver disease (Child-Pugh grading)
  • Child-Pugh classification grades severity of liver disease into A, B, C based on degree of ascites, encephalopathy, bilirubin, albumin, INR
  • Mortality is 32% Childs A, 46% Child B, 79% Child C
24
Q

What are the differentials for (lower GI) bleeding per rectum?

A
  • haemorrhoids
  • anal fissure
  • carcinoma of rectum
  • ulcerative colitis
  • Crohn’s colitis
  • Ischaemic colitis, carcinoma of colon, polyps, angiodysplasia
  • Torrential bleed
  • malignancy
  • diverticular disease
25
Q

What is the management of lower GI bleeding?

A
  • emergency resuscitation as already described
  • pharmacological:
    • stop NSAIDs/antiplatelets/anticoags if safe
    • tranexamic acid
  • endoscopic:
    • OGD (15% pts w/ severe acute PR bleed will have upper GI source)
    • colonoscopy - diagnostic + therepeautic (injection, diathermy, clipping)

Then also radiological and surgical (see next)

26
Q

What is the radiological management of lower GI bleeds?

A
  • CT angiogram - diagnostic only (non-invasive), helps determine site + cause of bleeding
  • mesenteric angiogram - diagnostic + therepeautic (but invasive) - determines site of beleding and allows embolisation of bleeding vessel, can result in colonic ischaemia
  • nuclear scintigraphy - technetium labelled red blood cells: diagnostic only, determines site of bleeding only (not cause)
27
Q

What is the surgical management of lower GI bleeds?

A
  • last resort in management as very difficult to determine bleeding point at laparotomy
  • segmental colectomy - where site of bleeding is known
  • subtotal colectomy - where site of bleeding unclear
  • beware of small bowel bleeding - always embarassing when bleeding continues after large bowel removed!

Gastroenterology (13 decks)

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