GI: Acute Abdomen, Upper GI Bleed & Ischaemic Colitis Flashcards
1
Q
Give some hepatobiliary causes & location of acute abdo pain
A
1) Biliary colic: RUQ
2) Acute cholecystitis: RUQ
3) Ascending cholangitis: RUQ
4) Acute pancreatitis: Epigastric, sometimes radiating through to the back
2
Q
Cause of biliary colic?
A
Caused by a gallstone getting lodged in the bile duct
3
Q
What is biliary colic clasically provoked by?
A
eating a fatty meal
4
Q
Is there signs of infection (fever/raised WCC) in biliary colic?
A
No (in contrast to acute cholecystitis)
5
Q
What is acute cholecystitis?
A
Inflammation/infection of the gallbladder secondary to impacted gallstones.
6
Q
Is there signs of infection (fever/raised WCC) in acute cholecystitis?
A
Yes
7
Q
What is Murphy’s sign?
A
1) asking the patient to take in and hold a deep breath while palpating the right subcostal area.
2) if pain occurs when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive.
8
Q
What condition is Murphy’s sign positive in?
A
Acute cholecystitis
9
Q
What is ascending cholangitis?
A
Ascending cholangitis is a bacterial infection of the biliary tree.
10
Q
What is the most common predisposing factor for ascending cholangitis?
A
Gallstones
11
Q
Additional features seen in ascending cholangitis?
A
Charcot’s triad of right upper quadrant pain, fever and jaundice occurs in about 20-50% of patients
12
Q
2 most common causes of acute pancreatitis?
A
lcohol & gallstaones
13
Q
Give some causes of generalised abdo pain?
A
Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
14
Q
Give some causes of RUQ pain
A
Biliary colic
Acute cholecystitis
Acute cholangitis
15
Q
Give some causes of epigastric pain
A
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm
16
Q
Give some causes of central abdo pain
A
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis
17
Q
Give some causes of LIF pain
A
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
18
Q
Give some causes of RIF pain
A
Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckel’s diverticulitis
19
Q
Give some causes of suprapubic pain
A
Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis
20
Q
Give some causes of loin to groin pain
A
Renal colic (kidney stones)
Ruptured abdominal aortic aneurysm
Pyelonephritis
21
Q
Give some causes of testicular pain
A
Testicular torsion
Epididymo-orchitis
22
Q
Give an upper GI cause abdo pain
A
peptic ulcer disease: epigastrium
23
Q
What may there be a history of in peptic ulcer disease?
A
NSAID use or alcohol excess
24
Q
Give some lower GI causes & location of abdo pain
A
1) appendicitis: RIF
2) acute diverticulitis: acute diverticulitis
3) intestinal obstruction: central
25
Describe pain in appendicitis
Pain initial in the central abdomen before localising to the right iliac fossa (RIF).
26
What other features may be seen in appendicitis?
Anorexia is common. Tachycardia, low-grade pyrexia, tenderness in RIF.
Rovsing's sign: more pain in RIF than LIF when palpating LIF
27
Describe pain in acute diverticulitis
Folicky pain typically in the LLQ
28
What other features may be seen in acute diverticulitis?
Diarrhoea, sometimes bloody.
Fever, raised inflammatory markers and white cells
29
What is there often a history of in intestinal obstruction?
History of malignancy (intraluminal obstruction) or previous operations (adhesions)
30
What are some urological causes & locations of abdo pain?
1) renal colic: loin pain radiating to groin
2) acute pyelonephritis: loin pain
3) urinary retention: suprapubic
31
Who is urinary retention more common in?
Men: especially with history of BPH
32
Describe pain in renal colic
Pain is often severe but intermittent. Patient's are characteristically restless.
33
What should be considered in all women of a reproductive age who present with abdominal pain?
All women of a reproductive age who present with abdominal pain should be considered pregnant until proven otherwise
34
How does ectopic pregnancy pain typically present?
- RIF or LIF pain
- History of amenorrhoea for the past 6-9 weeks
- Vaginal bleeding may be present
35
What are some vascular causes & locations of abdo pain?
1) Ruptured AAA: Central abdominal pain radiating to the back
2) Mesenteric ischaemia: Central abdominal pain
36
What do patients with mesenteric ischaemia often have a history of?
AF or other CVS disease
37
What metabolic disturbance is often seen in mesenteric ischaemia?
A metabolic acidosis is often seen (due to 'dying' tissue)
38
What is an upper GI bleed?
bleeding from the oesophagus, stomach or duodenum.
39
What are the 4 key causes of an upper GI bleed?
1) Peptic ulcer (most common)
2) Mallory Weiss tear (a tear of the oesophageal mucosa)
3) Oesophageal varices (2ary to portal hypertension in liver cirrhosis)
4) Stomach cancers
40
Clinical features of an upper GI bleed?
1) haematemesis (most common)
- often bright red
- can be 'coffee ground'
2) melena
- typically black and tarry
3) raised urea
- due to the 'protein meal' of the blood
4) may have haemodynamic instability from blood loss
- tachycardia
- hypotension
4) symptoms of particular diagnosis e.g.:
- oesophageal varices: stigmata of chronic liver disease e.g. ascites, jaundice, caput medusae
- peptic ulcer disease: epigastric pain & dyspepsia
- stomach cancer: weight loss, epigastric pain, treatment resistant dyspepsia, anaemia, raised platelets
41
What do Mallory Weiss tears tend to occur after?
Heavy vomiting or retching e.g. binge drinking, gastroenteritis, hyperemesis gravidarum (in early prengancy)
42
Give some oesophageal causes of an upper GI bleed
1) oesophageal varices
2) oesophagitis
3) cancer
4) mallory weiss tear
43
What is a Mallory Weiss tear? What are they typically associated with?
A tear or laceration in the distal oesophagus and proximal stomach.
Usually associated with forceful reaching or coughing (or strained defecation).
44
Risk factors for a Mallory Weiss tear?
1) alcoholism (40-80%)
2) hiatal hernia: retching increases the potential for mucosal laceration by creating a higher pressure gradient, in these patients
3) bulimia nervosa
4) hyperemesis gravidarum
5) GORD
45
How does a Mallory Weiss tear typically present?
Haematemesis:
- Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting.
Melena rare.
46
What is there typically a history of in oesophagitis?
GORD
47
How does oesophagitis causing an upper GI bleed typicallh present?
Small volume of fresh blood, often streaking vomit.
Melena rare.
47
What are oesophageal varices associated with?
Portal hypertension (increased portal venous system pressure) due to liver cirrhosis.
47
How does cancer causing an upper GI bleed typically present?
- Usually small volume of blood, except as a preterminal event with erosion of major vessels.
- Often associated symptoms of dysphagia and constitutional symptoms such as weight loss.
48
How does liver cirrhosis lead to oesphageal varices?
1) Cirrhosis causes backlog of blood through liver
2) This increases pressure in portal vein (that carries blood to liver): portal hypertension
3) Portal hypertension forces blood to seek out other pathways through smaller veins, such as those in the lowest part of the esophagus.
4) These thin-walled veins balloon with the added blood. Sometimes they rupture and bleed.
49
How does a GI bleed caused by oesophageal varices typically present?
1) haematemesis:
- usually large volume of FRESH blood
2) melena: from swallowed blood
3) often associated with haemodynamic compromise
50
What 2 drugs are used in the management of a variceal haemorrhage?
1) terlipressin (vasoactive agent)
2) prophylactic IV Abx (quinolones)
51
Management of variceal haemorrhage?
1) ABCDE
2) Correct clotting: FFP, vitamin K, platelet transfusions
3) Terlipressin
4) Prophylactic IV Abx e.g. quinolones (have been shown to reduce mortality in patients with liver cirrhosis)
5) Endoscopy: endoscopic variceal band ligation
52
When should terlipressin & IV Abx be given in variceal haemorrhage?
Prior to endoscopy.
53
What drug is used for the PROPHYLAXIS of variceal haemorrhage?
Propanolol: reduced bleeding & mortality
54
What are the 4 main gastric causes of an upper GI bleed?
1) gastric ulcer
2) gastric cancer
3) Dieulafoy lesion
4) diffuse erosive gastritis
55
How does an upper GI bleed caused by a gastric ulcer typically present?
1) Iron deficiency anaemia: as typically is a small low volume bleed.
2) Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.
56
How does an upper GI bleed caused by a gastric cancer typically present?
1) Haematemesis: may be frank haematemesis or altered blood mixed with vomit
2) Prodromal features: dyspepsia, constitutional symptoms
Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.
57
What is a Dieulafoy lesion?
A developmental vascular malformation of the GI tract. It is an enlarged submucosal blood vessel that bleeds in the absence of any abnormality, such as ulcers or erosions.
58
What are the 2 main duodenal causes of an upper GI bleed?
1) duodenal ulcer
2) aorto-enteric fistula
59
Where are duodenal ulcers usually located?
What vessel do they erode?
These are usually posteriorly sited and may erode the gastroduodenal artery.
However, ulcers at any site in the duodenum may present with haematemesis, melena and epigastric discomfort.
60
What scoring system is used at the initial presentation in suspected upper GI bleed?
Glasgow-Blatchford score
61
what does the Glasgow-Blatchford score estimate?
The risk of the patient having an upper GI bleed.
62
What Glasgow-Blatchford score indicates a high risk for an upper GI bleed?
Above 0
Consider early discharge in patients with a score of 0.
63
What causes a raised urea in an upper GI bleed?
Acid and digestive enzymes break down blood in the upper GI tract --> one of the breakdown products is urea, which is then absorbed in the intestines.
'Protein meal'.
64
What score is used after endoscopy to estimate the risk of rebleeding and mortality in an upper GI bleed?
Rockall score
65
What does the Rockall score indicate?
provides a percentage risk of rebleeding and mortality
66
How soon should patients with a suspected upper GI bleed have an endoscopy?
within 24 hours
67
How does the management of non-variceal vs variceal bleeding differ?
Non-variceal bleeding --> give PPIs (after proven on endoscopy)
Variceal bleeding --> give terlipressin & IV prophylactic Abx (before endoscopy)
68
Initial management of upper GI bleed:
(Mneumonic: ABATED)
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)
69
What should bloods be sent for in an upper GI bleed?
- Haemoglobin (FBC)
- Urea (U&Es)
- Coagulation (INR and FBC for platelets)
- Liver disease (LFTs)
- Crossmatch 2 units of blood
70
What is the difference between a 'group and save' and 'crossmatch'?
'Group & save': where the lab checks the patient’s blood group and saves a blood sample to match blood if needed.
'Crossmatch': where the lab allocates units of blood, tests that it is compatible, and keeps it ready in the fridge.
71
What transfusion products are given to patients with massive bleeding?
Blood, platelets and clotting factors (fresh frozen plasma)
72
When are platelets given in transfusion?
Platelets are given in active bleeding plus thrombocytopenia (platelet count less than 50)
73
What transfusion product can be given to patients taking warfarin that are actively bleeding?
Prothrombin complex concentrate
74
What investigation is required to diagnose and treat the source in an upper GI bleed?
Oesophago-gastro-duodenoscopy (OGD) (endoscopy) i
75
What are some ways in which non-variceal bleeding can be managed?
Clips or thermal coagulation.
76
What is often used to treat bleeding oesophageal varices?
Variceal band ligation
77
When should a PPI be given in patients with non-variceal upper GI bleeding?
AFTER endoscopy
78
What can blood product transfusion complications be broadly classified into?
1) immunological: acute haemolytic, non-haemolytic febrile, allergic/anaphylaxis
2) infective
3) transfusion-related acute lung injury (TRALI)
4) transfusion-associated circulatory overload (TACO)
5) other: hyperkalaemia, iron overload, clotting
79
What is a non-haemolytic febrile transfusion reaction caused by?
Thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage
Often the result of sensitization by previous pregnancies or transfusions
80
Features of a non-haemolytic febrile reaction?
Fever & chills
81
Is a non-haemolytic febrile reaction more common with RBC or platelet transfusion?
Platelet transfusion
82
Management of a non-haemolytic febrile reaction?
1) Slow or stop transfusion
2) Paracetamol
3) Monitor
83
What is a minor allergic transfusion reaction caused by?
Thought to be caused by foreign plasma proteins
84
Features of a minor allergic transfusion reaction
1) Pruritus
2) Urticaria
85
Management of a minor allergic transfusion reaction?
1) Temporarily stop transfusion
2) Antihistamine
3) Monitor
86
Who is anaphylactic reaction to transfusion thought sometimes seen in?
Can be caused by patients with IgA deficiency who have anti-IgA antibodies.
87
Features of anaphylactic reaction to transfusion?
1) hypotension
2) dyspnoea
3) wheezing
4) angiodema
88
Management of anaphylactic reaction to transfusion?
1) stop transfusion
2) IM adrenaline
3) ABC: O2 & fluids etc
89
What is an acute haemolytic reaction to transfusion thought to be caused by?
A mismatch of blood group (ABO) (e.g. secondary to human error) which causes massive intravascular haemolysis.
This is usually the result of red blood cell destruction by IgM-type antibodies.
90
Features of an acute haemolytic reaction to transfusion?
When do these symptoms begin?
1) fever
2) abdo pain & chest pain
3) hypotension
4) agitation
Symptoms begin minutes after the transfusion is started.
91
Management of an acute haemolytic reaction to transfusion?
1) stop transfusion immediately
2) confirm diagnosis:
- check the identity of patient/name on blood product
- send blood for direct Coombs test, repeat typing and cross-matching
3) fluid resuscitation with saline
92
What is a transfusion-associated circulatory overload (TACO) caused by?
1) Excessive rate of transfusion
2) Pre-existing heart failure
93
Features of transfusion-associated circulatory overload (TACO)?
1) pulmonary oedema
2) HTN
94
Management of transfusion-associated circulatory overload (TACO)?
1) slow or stop transfusion
2) consider IV loop diuretic (e.g. furosemide) & O2
95
What is a transfusion-related acute lung injury (TRALI) caused by?
Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood.
96
Features of a transfusion-related acute lung injury (TRALI)?
1) hypoxia
2) pulmonary infiltrates on CXR
3) fever
4) hypotension
97
Management of transfusion-related acute lung injury (TRALI)?
1) stop transfusion
2) O2 & supportive care
98
What are 2 main complications of an acute haemolytic transfusion reaction?
1) disseminated intravascular coagulation
2) renal failure
99
What is an infective transfusion reaction often associated with?
Transmission of vCJD.
100
What is ischaemic colitis?
An acute but transient compromise in the blood flow to the large bowel.
This may lead to inflammation, ulceration and haemorrhage.
101
Where is ischaemic colitis more likely to occur?
In 'watershed' areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.
102
Clinical features of ischaemic colitis?
Typically acute onset of symptoms (but can be chronic).
1) Abdo pain:
- usually localised to the LLQ or suprapubic region (corresponding to the affected segment of the colon)
- can be crampy in nature
- can range from mild to severe intensity
2) rectal bleeding
3) bowel habit changes:
- diarrhoea
- urgency
- tenesmus
4) N&V
5) systemic signs e.g. fever/tachycardia (can indicate systemic involvement or progression towards gangrenous colitis)
103
Mesenteric ischaemia vs ischaemic colitis?
Ischaemic colitis --> large bowel
Mesenteric ischaemia --> small bowel
104
What are the 3 main branches of the abdominal aorta that supply the abdominal organs?
1) coeliac artery
2) superior mesenteric artery
3) ifnerior mesenteric artery
105
What does the foregut include?
Stomach & part of duodenum, biliary system, liver, pancreas and spleen.
106
What artery supplies the foregut?
Coeliac artery
107
What is the midgut?
from the distal part of the duodenum to the first half of the transverse colon.
108
What artery is the midgut supplied by?
superior mesenteric artery.
109
What is the hindgut?
from the second half of the transverse colon to the rectum
110
What is the hindgut supplied by?
Inferior mesenteric artery
111
What is chronic mesenteric ischaemia also known as?
intestinal angina
112
What is chronic mesenteric ischaemia the result of
Narrowing of the mesenteric blood vessels by atherosclerosis causing ntermittent abdominal pain, when the blood supply cannot keep up with the demand (similar to pathophysiology of angina).
113
What classic triad of features is seen in chronic mesenteric ischaemia?
1) Central colicky abdominal pain after eating (postprandial): starting around 30 minutes after eating and lasting 1-2 hours
2) Weight loss (due to food avoidance, as this causes pain)
3) Abdominal bruit may be heard on auscultation
114
What typically precedes abdo pain in chronic mesenteric angina?
eating (approx 30 mins after)
115
Risk factors for chronic mesenteric angina?
same as CVS disease:
- Increased age
- Family history
- Smoking
- Diabetes
- Hypertension
- Raised cholesterol
116
How is a diagnosis of chronic mesenteric ischaemia made?
CT angiography
117
Management of chronic mesenteric ischaemia?
1) Reducing modifiable risk factors (e.g., stop smoking)
2) Secondary prevention (e.g., statins and antiplatelet medications)
3) Revascularisation to improve the blood flow to the intestines
118
What 2 options for revascularisation are there for chronic mesenteric ischaemia?
1) Endovascular procedures first-line (i.e. percutaneous mesenteric artery stenting)
2) Open surgery (i.e endarterectomy, re-implantation or bypass grafting)
119
What is acute mesenteric ischaemia typically caused by?
An thrombus/embolus causing occlusion of an artery which supplies the small bowel e.g. the superior mesenteric artery.
120
What is a key risk factor for acute mesenteric ischaemia?
AF:
Thrombus forms in the left atrium, then mobilises down the aorta to the superior mesenteric artery, where it becomes stuck and cuts off the blood supply.
121
Clinical features of acute mesenteric ischaemia?
Acute, non-specific abdominal pain --> pain is disproportionate to the examination findings.
Can go on to develop:
1) shock
2) peritonitis
3) sepsis
Over time, the ischaemia to the bowel will result in necrosis of the bowel tissue and perforation.
122
What is the diagnostic test of choice for acute mesenteric ischaemia?
Contrast CT --> allows the radiologist to assess both the bowel and the blood supply.
123
Lab findings in acute mesenteric ischaemia?
Patients will have metabolic acidosis and raised lactate level due to ischaemia.
124
Management of acute mesenteric ischaemia?
1) remove necrotic bowel
2) remove or bypass the thrombus in the blood vessel (open surgery or endovascular procedures may be used)
125
Prognosis of acute mesenteric ischaemia?
There is a very high mortality (over 50%) with acute mesenteric ischaemia.
126
What is mesenteric adenitis?
Mesenteric adenitis is inflamed lymph nodes within the mesentery.
It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two.
127
What does mesenteric adenitis often follow?
a recent viral infection
128
management of mesenteric adenitis?
needs no treatment
129
