GI Bleeding Flashcards
What is an upper GI bleed?
Blood loss whose origin is proximal to the ligament of Treitz at the duodenojejunal.
What are the manifestations of an upper GI bleed?
Haematemesis (active bleed), coffee ground emesis (slower) and melaena with or without haemodynamic compromise.
What are the manifestations of a lower GI bleed?
Haematochezia (bright red rectal bleeding) or blood mixed in with faeces helps localise where the bleed is.
What are the causes of an upper GI bleed?
- Peptic ulcer disease
- Varices
- Gastroduodenal erosions
- Mallory-Weiss tears
- Oesophagitis
- Malignancy (ALARM Signs)
What are the causes of lower GI bleed?
- Diverticular disease
- Angiodysplasia (small vascular malformation of the gut)
- Ischaemic colitis
- Inflammatory bowel disease
- Infectious colitis
- Colorectal cancer
- Haemorrhoids
What is this a presentation of?
Coffee ground vomit. NSAID/steroid use.
Peptic ulcer disease (blood lingering in the lumen allows oxidation of iron)
What is this a presentation of?
Brisk haematemesis, signs of liver disease or portal hypertension.
Variceal active upper GI bleed
What is this a presentation of?
Upper GI bleed which started as vomiting or retching without blood then blood appears.
Mallory-Weiss tear
What is this a presentation of?
Abdominal pain, diarrhoea, haematochezia.
Ischaemic or inflammatory colitis
What is the immediate management for a severe upper GI bleed?
- ABCDE, high flow oxygen
- 2 large bore cannulae
- FBC, U&Es, LFTs, clotting, crossmatch
- IV fluids (1-2L) or O Rh-ve if deteriorating.
- Transfuse 2 units with cross-matched blood if Hb <8.
- Correct clotting with vitamin K, FFP, platelets.
- IV Terlipressin 1-2mg/6hr if suspecting varices
- Urgent endoscopy, catheter, stop anticoagulation.
- Antibiotic prophylaxis
- Prevent encephalopathy
What is the management for rectal bleeding?
- ABCDE if necessary
- Treat cause
- History and examination
- FBC, U&Es, LFTs, clotting, cross-match
- AXR, erect CXR if signs of perforation
- IV access and catheterise
- Antibiotic cover if septic
- Withhold antiplatelet/anticoagulation
- Bed bound, stool chart
- If not settling conservatively - CT angiography, escalate to surgery
What scoring is used in Upper GI bleeding to assess mortality before and after endoscopy?
Rockall scoring system - admit all >0
Which medications are used in the prevention of peptic ulcer disease and varices rupture?
- PUD - PPIs
2. Varices - propranolol
What are the signs seen in a presentation of chronic liver disease causing portal hypertension?
Encephalitis with or without asterixis, spider angioma, gynaecomastia, hepatosplenomegaly, ascites, caput medusa, hypogonadism.
Which indication will help to identify an occult GI bleed?
Faecal occult blood test
What are haemorrhoids, how are they viewed, and in which positions can the three anal cushions be found?
- Disrupted and dilated anal cushions
- Viewed from lithotomy position
- 3, 7, and 11 o’clock
What are the differentials for haemorrhoids?
Anal fissure, tumour
What is the main cause of haemorrhoids?
Constipation with prolonged straining
What is this a presentation of?
Bright red rectal bleed, often coated stools, on the tissue or dripping into the pan after defecation. May have mucous PR, and pruritic ani.
Haemorrhoids
How are suspected haemorrhoids investigated in those >50 years old?
Abdominal exam, PR exam and colonoscopy.
What is the classification system for haemorrhoids?
- 1st degree - remain in the rectum
- 2nd degree - prolapse through anus on defecation but spontaneously reduces
- 3rd degree - same as second but requires digital reduction
- 4th degree - remains permanently prolapsed
Internal is above the dentate line external is below it.
What is the treatment for a first degree haemorrhoid?
Increase fluid and fiber intake, topical analgesics.
What is the treatment for a second and third degree or failed first degree haemorrhoid?
Rubber band ligation, sclerosants.
What is the definitive treatment for a fourth degree haemorrhoid?
Excisional haemorrhoidectomy
