GI Bleed Flashcards
Most common kind of GI bleed
Upper (80%)
How GI bleeds are classified
According to location, ligament of Treitz
Ligament of Treitz attaches to the third and fourth parts of the duodenum and the duodenojejunal flexure at the level of the inferior border of the first lumber vertebra
Proximal is UGIB
Distal is LGIB
Causes of UGIB
Classify as non variceal(80%) and variceal
Non variceal
- PUD (gastric and duodenal)
- Mallory Weiss syndrome
- Gastritis
- Oesopahigits
- Tumours (benign or malignant)
Variceal
- Gastroiesophageal varices
- Hypertensive portal gastropathy
Presentation of UGIB
According to severity of bleed,
Inspection
Range from alert to confused to comatose
Cardio respiratory distress, MM pale and dry, blue fingertips
Tachypneic, tachycardia, widened pulse pressure, hypotensive
No urine production
Haematochezia, haematoemesis, coffee grounds in emesis
Palpation
Cold and clammy extremities
Abdominal pain (epigastric if PUD or gastritis, RUQ if haemobilia,)
DRE melena
What is melena
Black, tarry, foul smelling stools need at least >50mL of blood to present with melena.
Due to gastric acid degradation, and action of digestive enzymes and bacteria in small intestine
Distinguish melena from iron supplements greenish stool with this test
Guaiac faecal occult blood test
(Negative in iron supplement green stained stool)
Presentation of LGIB
According to severity of bleed,
Inspection
Range from alert to confused to comatose
Cardio respiratory distress, MM pale and dry, blue fingertips
Tachypneic, tachycardia, widened pulse pressure, hypotensive
No urine production
Palpation
Cold and clammy extremities
Abdominal pain (LLQ for diverticulitis)
DRE bright red blood per rectum
Causes of LGIB
Vascular
- Angiodysplasia
- Diverticula
- Mesenteric ischaemia
- Hameorrhoids
Tumour (benign and malignant)
Trauma
- Anorectal fissure
Inflammatory
- UC
Risk factors for bleeding
Bleeding disorders
- platelet dysfunction or thrombocytopenia
- clotting factor deficiency
Drugs
- heparin
- warfarin
- aspirin
- selective serotonin reuptake inhibitors
Disseminated intravascular coagulation
What is an angiodysplasia
Degenerative lesions of blood vessels in submucosa of intestine that lead to progressive vasodilation and bleeding when submucosa eroded
Common to right side of colon (caecum)
Angiodysplasia appearance on colonoscopy
Red stellate lesion with surrounding rim of pale mucosa
Collection of dilated venues along atrium appearing as red streaks in a longitudinal fashion and giving antrum a watermelon appearance
Gastric arterial vascular ectasia
What is Dieulafoys lesion
Vascular malformation in stomach within 6cm of gastro oesophageal junction
Unusually large vessels 1-3mm found in gastric submucosa which tend to bleed with erosion of the mucosa
One cause of massive UGIB
Variceal haemorrhage
- usually at distal 3-5cm of oesophagus
- up to 1-2cm in size
Erosion of pancreatic pseudocyst in splenic artery
Presents with abdominal pain and haematochezia
Haemosuccus pancreaticus
Management of UGIB
A and B - check airway patency and suction, check breathing, oxygen administration as needed, intubation as needed
C - Check pulse, blood pressure
Site 2 16 gauge IV accesses
Give crystalloid fluids like Ringers lactate 3ml to ever ml of blood loss
If unstable bolus 2L Ringers lacate
Insert Foley catheter
Take off bloods for
*complete blood count
*Urea and electrolytes
*Platelets, prothrombin time, partial thromboplastin time, liver function tests
*Group and cross match
Locate site of bleeding - pass nasogastric tube, endoscopy - oesophagogastroduodenoscopy
Endoscopic interventions for GIB
Epinephrine
Electrocautery
Sclerotherapy
Clips
Management of LGIB
A and B - check airway patency and suction, check breathing, oxygen administration as needed, intubation as needed
C - Check pulse, blood pressure
Site 2 16 gauge IV accesses
Give crystalloid fluids like Ringers lactate 3ml to ever ml of blood loss
If unstable bolus 2L Ringers lacate
Insert Foley catheter
Take off bloods for
*complete blood count
*Urea and electrolytes
*Platelets, prothrombin time, partial thromboplastin time, liver function tests
*Group and cross match
Locate site of bleeding - colonoscopy
GIB surgery indications
Haemodynamically unstable despite vigorous resuscitation
Prolonged bleeding requiring >3-6 units PRBCs
2 failed endoscopic interventions to stop bleeding
Hypovolemia shock
Detects .1ml/min blood flow but is the LEAST ACCURATE in localizing site of bleed
Radionuclide scan technetium 99
Detects blood flow .5 - 1ml/min usually used to localize bleeding site in ongoing haemorrhage
Mesenteric angiography
Traditional angiogram
Therapeutic advantages of traditional angiogram
Vasopressin infusion
Embolization (gelatin infusion or coils)
No bowel prep needed
Ct angiogram is NOT THERAPEUTIC
Management for Diverticular disease and angiodysplasias bleeding
Endoscopic - epinephrine, electrocautery, sclerosant or clips
Conventional Angiography - vasopressin or embolization
Surgery - if other measures fail, surgical resection
Ct findings of Mesenteric ischaemia
Thickened bowel wall
