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Block 32 GI and surgery > Gastrointestinal Bleeding > Flashcards

Gastrointestinal Bleeding Flashcards

1
Q

name the common causes of upper GI bleeding?

A
  • peptic ulcer disease (35-50%)
  • gastroduodenal erosions (8-15%)
  • oesophagitis (5-15%)
  • mallory weiss tear (15%)
  • varices (5-10%)
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2
Q

name some of the less common causes of upper GI bleeding?

A
  • upper GI malignancy
  • vascular malformations
  • facial trauma
  • nose bleed
  • haemoptysis
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3
Q

what is the typical presentation of peptic ulcer disease?

A
  • NSAID history (often with corticosteroids)
  • Past ulcers
  • Indigestion of food often improves pain
  • Coffee ground emesis and haematemesis
  • Mid epigastric tenderness to palpating
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4
Q

what is the basic pathophysiology of peptic ulcer disease?

A

Break in superficial epithelial cells penetrating down to the muscularis mucosa in stomach or duodenum, there is a fibrous base and increase in inflammatory cells. Erosions are superficial breaks in the mucosa. Can be due to NSAID use or H.pylori.

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5
Q

what is the typical presentation of oesophagitis?

A
  • Often seen in GORD
  • Associated with dysphasia or odynophagia
  • Globus sensation, hoarseness
  • Many patients who present with Melaena who are suspected of peptic ulcer disease actually have oesophagitis
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6
Q

what is the basic pathophysiology of oesophagitis?

A

the lower oesophageal sphincter prevents acid from entering the oesophagus. If the sphincter is not tight, it may allow acid to enter the oesophagus, causing inflammation of one or more layers. oesophagitis may also occur if an infection is present.
Irritation can be caused by GORD, vomiting, surgery, medications, hernias, and radiation injury. Inflammation can cause the oesophagus to narrow, which makes swallowing food difficult and may result in food bolus impaction.

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7
Q

what is the basic presentation of a mallory-weiss tear?

A

Hematemesis following retching or vomiting
Alcohol use, advanced age, presence of hiatal hernias are common underlying features
Bleeding can be accompanied by mid-epigastric or retro sternal pain

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8
Q

what is the basic pathophysiology of mallory-weiss tear?

A

often associated with alcoholism and eating disorders and some evidence that presence of a hiatal hernia is a predisposing condition. Forceful vomiting causes tearing of the mucosa at the junction. In rare instances some chronic disorders like Ménière’s disease that cause long term nausea and vomiting could be a factor. The tear involves the mucosa and submucosa but not the muscular layer.

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9
Q

what is the presentation of gastric varices?

A

History of intravenous drug use that could lead to chronic hepatitis, chronic alcoholism or cirrhosis. Associated with massive bleeding and rapid haemodynamic compromise
Stigmata of chronic liver disease are often present (eg jaundice, hepatomegaly, splenomegaly, ascites)

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10
Q

what is the basic pathophysiology of gastric varices?

A

-dilated submucosal veins in the stomach, can be a life-threatening cause of upper GI bleeding.
seen in patients with
-portal hypertension, (may be a complication of cirrhosis.).
-thrombosis of the splenic vein, into which the short gastric veins which drain the fundus of the stomach flow.
-complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours, as well as hepatitis C.
- schistosomiasis resulting from portal hypertension.

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11
Q

what affect does age have on suspected diagnosis in patient presenting with upper GI bleed?

A

student - oesophageal rupture

older patient - malignancy

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12
Q

describe the common presentation of an upper GI bleed?

A

Hematemesis
Coffee ground emesis
Melena
Occasionally hematochezia (bright red blood in stools)
Haemodynamic instability, abdominal pain, symptoms of anaemia eg lethargy, fatigue, syncope and angina.
Acute bleeding usually have normocytic RBC where as microcytic red blood cells or iron deficiency suggests chronic blood loss
Anatomic and vascular causes=painless, large volume blood loss
Inflammatory causes=diarrhoea and abdominal pain

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13
Q

describe the common presentation of a lower GI bleed?

A

Hematochezia
Bleeding from right colon or small intestine can present with melena. Darker and mixed
Bleeding from left side of colon-bright red
Haemodynamic instability, abdominal pain, symptoms of anaemia eg lethargy, fatigue, syncope and angina.
Acute bleeding usually have normocytic RBC where as microcytic red blood cells or iron deficiency suggests chronic blood loss
Acute lower GI bleeding normally have normal urea to creatinine ratio
Anatomic and vascular causes=painless, large volume blood loss
Inflammatory causes=diarrhoea and abdominal pain

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14
Q

what are the common causes of acute lower GI bleed?

A 
diverticular disease
mesenteric ischaemia 
angiodysplasia 
ischaemic colitis 
Meckel's diverticulum
intussusception
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15
Q

what blood tests would you perform in a patient with a GI bleed

A 
cross match 
check FBC
LFTs
U&E
Clotting
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16
Q
  1. what would blood tests in a patient with large upper GI bleed show?
  2. what other investigation would be performed in acute GI bleed within 24 hours?
A
  1. Hb to drop and urea to rise (if platelets drop-it points to liver disease)
  2. endoscopy
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17
Q

what differentials are more likely in CHRONIC GI bleed?

A

malignancy such as gastric or colorectal

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18
Q

what is given to treat oesophageal bleeding due to varices?

A

terlipressin

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19
Q

describe the initial management of acute GI bleed?

A
  • admit, ABCDE
  • blood tests
  • varlipressin if suspect varices
  • upper GI endoscopy within 24 hours
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20
Q

describe the management of varices?

A
  • banding/ sclerotherapy (where bleeding is active, insert Minnesota tube and inflate gastric before oesophageal balloon).
  • Medical therapy & TIPSS can be used to lower portal pressure
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21
Q

Describe the management of erosive oesophagitis/gastritis?

A
  • PPI (and withdrawal of any NSAIDs/ steroids they’re on).

- Erosive gastritis which cannot be controlled may need gastrectomy.

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22
Q

describe the management of a mallory-weiss tear?

A

tend to resolve on their own; any bleeding points located can be hit with adrenaline & diathermy/ clamp. Everyone should get a PPI to reduce re-bleeds.

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23
Q

what intervention is needed to manage a bleeding ulcer than can’t be controlled endoscopically?

A

laparotomy and ulcer underrunning (undersewing)

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24
Q

what are the differentials for blood noticed IN stools?

A
  • IBD

- diverticulitis

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25
Q

what are the differentials for blood noticed WITH stools?

A
  • haemorrhoids
  • bowel cancer
  • constipation->perianal damage->anal fissure
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26
Q

in general when is blood found

  1. with stools
  2. in stools
A
  1. perianal

2. rectum or above

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27
Q

what are the associated symptoms with rectal bleeding?

A
  • Haematemesis
  • Abdominal pain
  • Rectal pain-when passing stools (pooping glass?)
  • Bloating
  • Weight loss
  • Mucous
  • Change in bowel habit
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28
Q

why is history of liver disease important to consider with rectal bleeding?

A

liver failure can cause problems with clotting factors and patients often get rectal varices

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29
Q

why is family history important to consider in a patient with rectal bleeding?

A

familial ademomatous polyposis.
autosomal dominant
polyps that start out benign but become malignant if untreated

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30
Q

why is drug history important to consider in patients with rectal bleeding?

A

opioids have common side effects of constipation which could cause anal fissures

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31
Q

why is diet important to consider in a patient with rectal bleeding?

A

low fibre increases likelihood of constipation and both low fibre and high red meat increases cancer risk

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32
Q

why is smoking and alcohol consumption important to consider in a patient with rectal bleeding?

A

smoking increases risk of malignancy

alcohol has a dose response relationship with bowel cancer (diabetes has no link to bowel cancer)

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33
Q

what are the appropriate initial investigations for a GI bleed?

A

-FBC
-LFTs
-group and save
-U&Es
-urea
-coagulation
-PR examination
[in acute phase of bleed imaging isn’t first line]

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34
Q

In GI bleeding what is the purpose of testing for

  1. LFTs
  2. group and save
  3. U&Es
  4. urea
A
  1. screen for liver disease
  2. ABO and rhesus matching for possible blood transfusion
  3. check kidney function and perfusion.dehydration
  4. it is a protein breakdown product so it is expected to go up. patient digesting blood
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35
Q

In GI bleeding what is the purpose of testing

  1. coagulation
  2. blood
  3. PR examination
  4. FOB/FIT test
A
  1. get a good INR and APPT to see what clotting is like
  2. probably be anaemic. may tell you nature of cause eg inflammatory
  3. give idea of what clotting is like
  4. if they don’t report blood in the stools you should check if they actually have melaena
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36
Q

what are the red flag symptoms for colon symptom?

A
  • older demographic
  • change in bowel habit for 6 weeks (loose, increased frequency)
  • blood in stools (bright red)
  • weight loss
  • family history
  • palpable masses (in right and rectal regions, if in lower left quadrant it could be faecal loading)
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37
Q

what is the initial management for a patient with an acute GI haemorrhage?

A
  • Cannulate in both antecubital fossae (dual cannula)
  • IV fluid (crystalloid)
  • Platelets (Depending on level)
  • Blood (depending on level)
  • Catheter – monitor urine output
38
Q

when is endoscopy done in a patient with GI bleed?

A

within 24 hours of hospital admission

unless bleeding is profuse in which case it is done by out of hours on call endoscopists

39
Q

what may be found on endoscopy in a patient with GI bleed?

A
  • Active, spurting haemorrhage
  • Non-bleeding blood vessel visible within an ulcer
  • Red spots on large varices – associated with increased risk of further bleeding
40
Q

what is the prognosis if stigmata aren’t present?

A

-smaller risk of re-bleeding and greater likelihood of early discharge from hospital.
Diagnostic endoscopy may not improve outcome, but it does inform prognosis because it helps with treatment planning.

41
Q

what are the typed of interventional endoscopic procedures?

A
  • Thermal – e.g. heater probe, multipolar electrocoagulation
  • Pharmacological injection – adrenaline, alcohol, procoagulants, sclerosants.
  • Mechanical – clips, sutures, staples, band ligation
42
Q

what is the best methods to deal with non-varicael bleeding?

A

injection combined with thermal method

43
Q

what is the best method to deal with varices?

A

intravariceal injection of sclerosant or oesophageal band ligation (more efficient and has fewer complications but is difficult to perform in an actively bleeding patient)

44
Q

how often does endoscopic treatment fail?

A

about 20% of patients with bleeding ulcers.

45
Q
  1. what are the iatrogenic causes of variceal bleeds?

2. what are the infectious causes of variceal bleeds?

A
  1. steroids / NSAIDs (PPI for gastric protection)

2. H.pylori

46
Q

how can GPs aid in the prevention of GI bleeds?

A
  • Lifestyle modification: minimising alcohol consumption
  • Gastric protection for prescribed drugs (i.e. prescribing PPIs to protect against gastric ulcers in elderly patients with NSAIDs and steroids)
47
Q

what is angiodysplasia and how do they cause bleeds?

A

when you have abnormal or enlarged blood vessels in your GI tract. These blood vessels can become fragile and bleed.

48
Q

how do benign tumours/cancer cause GI bleeds?

A

Benign tumours and cancer in the oesophagus, stomach, colon, or rectum may cause bleeding when they weaken the lining of the GI tract. A benign tumour is an abnormal tissue growth that is not cancerous

49
Q

how does colitis cause GI bleeding?

A

Ulcers in the large intestine are a complication of colitis. Ulcerative colitis is an inflammatory bowel disease that can cause GI bleeding.

50
Q

what is the significance of colon polyps?

A

Colon polyps can cause GI bleeding. You can have more than one colon polyp at a time. Some types of polyps may be cancerous or can become cancerous.

51
Q

how does diverticular disease cause GI bleeding?

A

small pouches, or sacs, form from the muscular lumen and push outward through weak spots in the colon wall.

52
Q

how can hernias lead to GI bleeding?

A

Can be rolling or sliding, moving with breathing which end up causing erosion and leading to ulcer formation. The ulcer could get so deep it damages arteries resulting in bleeding.

53
Q

what condition is oesophageal varices usually associated with?

A

chronic liver disease

cirrhosis

54
Q

what is the most common cause of oesophagitis and how does this occur?

A

gastrooesophageal reflux
which occurs when the lower oesophageal sphincter is weak or relaxes when it shouldn’t. stomach acid can damage the oesophagus and cause sores and bleeding

55
Q

list some common causes of gastritis?

A
  • NSAID use
  • infections
  • Crohn’s
  • MUS
  • serious illnesses
  • severe injuries
56
Q

what is the consequence of untreated gastritis?

A

lead to ulcers or worn away areas of stomach lining that may cause bleed

57
Q

describe haemorrhoids?

A

can cause GI bleeding. Constipation and straining during bowel movements cause haemorrhoids (blood vessels in smooth muscles of rectum and anus) to swell. Haemorrhoids cause itching, pain, and sometimes bleeding in your anus or lower rectum

58
Q

what are anal fissures?

A

small tears that also can cause itching, tearing, or bleeding in your anus

59
Q

what is the epidemiology of colorectal cancer?

A

3rd most common cancer in western world. Rare below age of 40 (99% in people aged over 40)

60
Q

what is the epidemiology of diverticular disease?

A

Incidence increases with age. Lower incidence in vegetatians

61
Q

what is the epidemiology of haemorrhoids?

A

More common in white patients. Most cases between 45-65

62
Q

what is the epidemiology of anal fissure?

A

1 in 350 adults. Age 15-40. can occur in children

63
Q

what is the aetiology of colorectal cancer?

A

Age-most cases are in people over 60
Family history-first degree relative under 50
Diet-high in red and processed meat
smoking, alcohol, obesity, inactivity, digestive disorders
Genetic conditions-FAP, HNPCC

64
Q

what is the aetiology of diverticular disease?

A

Genetic and environmental. Low dietary fibre intake, decreased physical activity, obesity, increased red meat, alcohol, caffeine, steroids, NSAIDs

65
Q

what is the aetiology of haemorrhoids?

A

Excessive straining due to chronic constipation or diarrhoea. Repetitive or prolonged straining causes downward stress on vascular haemorrhoidal cushions-disruption of supporting tissue elemens with elongation, dilation, engorgement of haemorrhoidal tissues. Other condition can contribute-increased intra-abdominal pressure such as pregnancy or ascites, space occupying lesions in pelvis, increase in anal vascular engorgement

66
Q

what is the aetiology of anal fissures?

A

Passage of hard stool may precipitate. May begin during period of loose stool. Often occurs spontaneously. Hard stools tear anal skin from pectin at dentate line but may also be due to ischaemia and deficiency in intrinsic NO synthase pathway

67
Q

what are the causes of rectal bleeding?

A 
haemorrhoids
anal fissures
carcinoma (colorectal)
IBD
diverticular disease
chronic infecions
colorectal polyps 
ischaemic colitis 
angiodysplasia of colon
bleeding diathesis 
rectal prolapse
68
Q

describe the presentation of haemorrhoids?

A

Bleeding after defecation, fresh blood drops, spurting of blood lump out of anus, perianal discomfort

69
Q

describe the presentation of anal fissures?

A

Fresh blood streaked on stools, pain (sharp, severe, start with defecation, lasts for hours)

70
Q

describe the presentation of colorectal cancer?

A

Fresh blood following defecation (rectal). Altered blood mixed with stools (sigmoid or descending). Painless, tenesmus, incomplete evacuation. Altered bowel habits,

71
Q

describe the presentation of IBD?

A

Blood and mucus diarrhoea, painless unless fissure, systemic symptoms such as low grade fever

72
Q

Describe the presentation of diverticular disease?

A

Blood and mucus diarrhoea, painless unless fissure, systemic symptoms such as low grade fever

73
Q

what are the investigations for rectal bleeding?

A
  • bloods
  • serum urea: creatinine
  • stool culture
  • CT angiography
  • Endoscopy
74
Q

what routine bloods are done to investigate rectal bleeding?

A 
FBCs
U&E
LFT
coagulation studies
acute bleeds may not initially show reduced Hb
75
Q

why is serum urea:creatinine tested in patients with rectal bleeding?

A

<30:1 suggests upper GI bleed

76
Q

why are stool cultures tested for in patients with rectal bleeding?

A

exclude infections

77
Q

when is CT angiography done following a GI bleed?

A

when no diagnosis has been made from endoscopy

78
Q

what types of endoscopy are carried out following rectal bleeding?

A
  • flexible sigmoidoscopy
  • full colonoscopy
  • if haemodynamically unstable-emergency upper GI endoscopy
79
Q

when may surgical interventions be needed in rectal bleeding?

A

ongoing lower GI bleeding with instability where endoscopic and radiographic treatment has failed

80
Q

what is the first line management of haemorrhoids?

A

-Dietary & lifestyle modification – increase fibre (25-30g /day) & fluids
decrease straining & time on toilet
moist gentle cleaning following a bowel movement.
Where there are additional symptoms (e.g. altered bowel habit, abdominal pain, weight loss, iron deficiency anaemia and mucous), colonoscopy is performed.

81
Q

what are the other methods used to manage haemorrhoids?

A
  • Topical corticosteroids - where haemorrhoids are grade 2 prolapsing internal, these can be used as an adjunct.
  • Rubber band ligation – for grade 3 prolapsing or grade 4 internal, external/ mixed internal and external.
  • Last resort: Surgical haemorrhoidectomy
82
Q

what is an anal fissure?

A

split in skin of distal anal canal, characterised by severe pain on defecation (like pooping glass) and rectal bleeding (blood will appear fresh and with stools)

83
Q

what are the risk factors for anal fissures?

A

hard stools, pregnancy and opiate analgesia (as these cause constipation).

84
Q

what is the first line management of anal fissures?

A

conservative – high fibre & fluid intake, sitz baths, topical analgesia. Stool softeners would be handy to reduce pain on defecation (and treat constipation as the underlying cause)

85
Q

what is the other treatment of anal fissures?

A
  • Topical glyceryl trinitrate or topical diltiazem would be recommended as adjuncts to conservative treatment.
  • For resistant fissures, botox and surgical sphincterectomy would be first-line.
86
Q

describe rectal bleeding in IBD?

A

Rectal bleeding – will come from higher up than the rectum so you’ll expect it to be mixed in the stools

87
Q

what investigations are done in IBD?

A

PR exam, FBC, U&Es, CRP, ESR, Abdominal X ray (to rule out small bowel obstruction), CT abdomen, Colonoscopy (for both), endoscopy (Crohn’s) & mucosal biopsy

88
Q

what is the management for IBD?

A

biological therapies (steroids)

89
Q

describe rectal bleeding seen in patients with diverticular disease?

A

Rectal bleeding will come from higher up than the rectum, so you’d expect blood to be mixed in the stools. Most patients will be >50
LLQ pain, fever, bloating and constipation

90
Q

what are the investigations for diverticular disease?

A

FBC, U&Es, CRP, abdominal X-ray, CT abdomen

91
Q

describe GI blood loss seen in malignancy?

A

would expect blood to be much less obvious and mixed into the stools, possibly also mucous, no pain so presentation is more likely to be late with symptoms of anaemia. History would highlight polyps, family history of malignancy & risk factors such as smoking.

92
Q

what are the investigations with suspected malignancy?

A

FBC, FOB, CRP, Faecal calprotectin, CEA (non-specific cancer marker – would be raised in bowel cancer).
Management: resection, radiotherapy, chemotherapy etc.

Block 32 GI and surgery (12 decks)

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