GI bleeding Flashcards
What signs should be recognised as potential upper GI bleed
Haematemesis
Coffee ground vomit
Melana
Resus for upper GI bleed management. When transfuse?
NEWS
IV crystalloid
Transfuse if Hb below 70g/L. (aim for 70-100)
What do you use to risk assess an upper GI bleed?
Glasgow Blatchford Score
What should you give if sus varices
Terlipressin 2mg IV
Antibiotics as trust protocol
Continue aspirin
Suspend other antithrombotics
What investgiation should refer to and when with upper GI bleed?
Endoscopy in 24 hours of presentation
GI specialist if require therapeutic endoscopy
When should you activate major haemorrhage protocol and critical care review?
Haemodynamic instability
What landmark sperates upper and lower sources of GI bleeding?
Ligament of Treitz (suspensory ligament of the duodenum, suspends the duodejejunal flexure form the retroperitoneum)
How does bleeding above vs below the ligament of Treitz present?
Above -> haematemesis or melana
Below -> haematachazia (passing blood)
What is melaena?
Dark, black and tarry stool
Strong odour - digestion of haemoglobin
How to differentiate between iron induced black stool and melaena?
Iron will have a green tinge when spread thinner, melaena wont
Common causes of upper GI bleed list
Gastric and/or duodenal ulcers
Severe or erosive gastritis/duodenitis
Severe or erosive esophagitis
Esophagogastric varices
Portal hypertensive gastropathy
Angiodysplasia (also known as vascular ectasia)
Mallory-Weiss syndrome
Mass lesions (polyps/cancers)
No lesion identified (10 to 15 percent of patients)
Symptoms of Mallory Weiss syndrome
- Emesis
- Retching
- Coughing prior to haematemesis
Signs that indicate variceal bleed
jaundice
Ascites
Which peptic ulcer pain is relieved by eating?
Duodenal
Why is duodenal ulcer pain relieved by food?
Presence of food in the stomach triggers release of digestive juices which are alkaline and relieve the acidic pH
If the patient complains of pain when they eat which ulcer is it more likely t be?
Gastric
Symptoms peptic ulcer
Dyspepsia
Central burning chest pain
Signs of malignancy causing upper GI bleed
- Dysphagia
- early satiety
- Cachexia
- Involuntary weight loss
When is haematachezia seen with an upper GI bleed
When the bleed is massive
Why can upper GI bleeds be associated with orthostatic hypotension
When they are big enough to cause haemodynamic instability
History questions ass symptoms with upper GI bleed
painless vs. painful
trouble swallowing
unintentional weight loss
preceding emesis or retching
change in bowel habits
Symptoms of an oesophageal ulcer
Odynophagia, GORD, dysphagia
What is important to consider in a patient with a history of AAA or aortic graft with an upper GI bleed?
Aorto-eneteric fistula - abnormal connection between the aorta and the blood supply to the GI tract
What is angiodysplasia and how diagnosed
an abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract.
Diagnosed with colonoscopy or angiography
What PMH is important when considering an angiodysplasia?
Renal disease
Aortic stenosis
Hereditary haemorrhagic telangiectasia
What are risk factors for peptic ulcer diseas?
H.pylori infection
Smoking
NSAID use
Antithrombotic use
What should you especially consider if H.pylori infection, exccess alcohol and smoking are in the history?
Malignancy
Peptic ulcer disease
What could cause upper GI bleed in a patient with gastroenteric anastomosis
Marginal ulcers - ulcers at an anastomic site
What conditions can cause overload in rigorous fluid resus?
CKD, HF
What patients is anaemia especially dangerous in?
IHD
What to assess for in exam for upper GI bleed
Full A to E if acute
Hypovolaemia
Resting tachycardia
Orthostatic hypotnesion
Supine hypotnesion
Signs of liver disease
PR exam
-anal fissures
Haemorrhoids
Anorectal mass
Stool exam
Which bloods ask for in upper GI bleed?
FBC
G+S
INR, PT, APTT
Lactate
LFTs
Renal function - U+Es
Urea may be elevated
CRP
B12/folate/ferritin
Why is urea sometimes eleated in upper GI bleed?
Proteins in blood absorbed in GI tract and transported to kidney - increased waste product
What does a low MCV suggest about the casue of a bleed?
Iron deficiency anaemia, chronic bleeding
Differentials for an upper GI bleed
Peptic ulcer disease
GE varices
Upper GI cancers - oesophageal, gastric
Erosive oesophagitis/gastritis/duodenitis
Mallory Weiss tear
Causes of haemotachezia
Diverticulitis
Colitis: -IBD - Crohns, UC. -Ishcaemic -Infective, C.difficile
Colorectal cancers
Haemorrhoids
Anal fissure
What ass symptoms should you ask about with a GI bleed?
Pain
GI Upset
Nausea/vomiting
Diarrhoea
Constipation
Mucus in stool
Pale stool
Malaena (indicating UGI bleed, which has been digested and excreted, of sufficient volume to alter stool composition)
Dark urine - indicating possible obstructive jaundice
Water brash
Dysphagia
Dyspepsia (ALARMS symptoms)
Reduced appetite
Weight loss
Flatus
Bloating
Tenesmus
Early satiety
Perianal itch.
What diagnosis would be most likely in a young patient with diarrhoea, mucus in stool ad haematochezia?
IBD
Get travel history
What diagnosis would be most likely in a older patient with L iliac fossa pain and haemotachezia?
Diverticulitis
What sort of vimtting is seen in a Mallory-Weiss tear?
Profuse with no blood initially then streaks of fresh blood
What does jaundice and haematemesis signal?
Oesophageal varices rupotured
What diagnosis does dyspepsia nad coffee ground vomit suggest?
Peptic ulcer disease
What symptoms make infective colitis/dysentry like;ly?
Fevers, bloating, acute D/V, unusualy food and heamatochezia, recent travel
Main symptoms of haemorrhoids
Tenesmus, perianal itch and constipation with heamatochezia
What is proctalgia?
Pain around anus/rectum
What symptoms make an anal fissure more likely?
Constipation
Blood on wiping after passing stoll
Proctalgia
What bacteria may be implicated in haemolytic uraemic syndrome?
E.Coli O157
What orgnaism is teh most common cause of bloody diarrhorea?
Shigella dysentriae
What is the most common cause of gastroenteritis?
Norovirus. Blood noy normally present
What does Shigella dysentriae cause?
Severe inflammation and necrosis in colon epithelium
What is Giardia Lamblia?
Parasitic infection causing malabsorption, abdominal pain, bloating and diarrhoea with steatorrhea
What are large volume GI bleeds more likely to be?
varices, peptic ulcer disease, diverticulitis, colitis.
What does H.pylori increase your risk of?
Peptic ulcer disease
Gastic cnacer
Why are IBD patients at a higher risk of cancer
Chronic intestinal inflammation
Immunosupression
Why is pain worse at night and can wake patients with a duodenal ulcer up?
When the stomach is empty there are continour secretions moving through to the duodenum -> irritate ulcered area
What is alendronate
A Bisphosphonate
Which inherited condition increases the risk of a variety of cnacers?
HNPCC hereditary non polyposis colorectal cancer
Why do polyunsaturated fats increase you risk of cancer?
Increased cholesterol secretions which are broken down into potential carcinogens in GI tract
WHich GI conditions does smoking increase the risk of?
PUD
GI cancer
Flares of Crohns
Steps to manage an acute upper GI bleed
1) Stabilise the patient (fluid resusitation, transfusions, reversal of anticoagulation, Terlipressin)
2) Risk stratification based on Rockall and Blatchford Scoring systems
3) Endoscopic management in due course
What score is used to assess upper GI bleeding?
Rockall score
Features of the rockall socre
Age, shock, comorbidity, diagnosis (eg MW tear = o, GI malignancy - 2)
Evidence of bleeding
What score strratifies high and low risk upper GI bleeds?
Glasgow-Blatchford bleeding score. Any risk higher than 0 needs intervention
Management of acute upper GI bleed
https://www.nice.org.uk/guidance/cg141/resources/acute-upper-gastrointestinal-bleeding-in-over-16s-management-pdf-35109565796293
Make more flash cards off NICE guidance
What GI condition can CVS issues predispose to?
Ischaemic colitis
How does ischaemic colitis cause metabolic acidosis?
Raises lactate levels
Evidence of diverticulits on CT
Thickening of bowel wall
Enhancement of colonic wall
Dark spot at centre=diverticula
GI bleed symptoms to ask
- Pain
- GI Upset
- Nausea/vomiting
- Diarrhoea
- Constipation
- Mucus in stool
- Pale stool
- Malaena
- Dark urine - indicating possible obstructive jaundice
- Water brash
- Dysphagia
- Dyspepsia (ALARMS symptoms)
- Reduced appetite
- Weight loss
- Flatus
- Bloating
- Tenesmus
- Early satiety
- Perianal itch.
Most common cause of bloody diarrhoea?
Shigella dysentriae
Initial management GI bleed
Ensure good IV access - 2 green venflows minimum
Criteria for central line insertion
Severe shock
Rebleeding
Severe comorbidity ehere CVP monitoring adventageous eg cardiac or renal failure
Difficult/poor peripheral access
What Rockall score is mod to severe risk?
3-7
What rockall score is mild to mod risk?
0 -2
Factors Rockall score
Age - <60, 60-79, >79
Stigmata of shock - tachy, hypotension <100
Co-morbidity - IHD/CVA/COPD, renal/liver failure, disseminated mailgnancy
What is the Glasgow blathcford score?
For bleeding
Blood urea
Haemoglobin for men or women
other markers =
pulse, melaena, syncope, hepatic disease, cardiac failure
Initial management diarrhoea, tachycardic, bleeding, on warfarin
IV fluid bolus then maintenance
Reveres patients wararin with vit K
Start on broad specturm antibioitcs
Adequate analgesia - NOT NSAIDs
Disscuss with surgical registrat on call
Bleeding disorders family history
Von Willebrands disease
Haemophilia A
Factor V leiden
Antiphospholipid syndrome
Hereditary family bowel conditions
Herediatry non-polyposis colorectal cancer
Familial adenomatous polyposis
What drugs can cause GI bleed?
Bisphosphonates - inflammation, ulcers, strictures, gastritis, upper GI blees
Anticoagulation - reverse
NSAIDs
Sreroids - risk of ulcers
PPIs/H2 receptor anatagonists - protective, suggests prev problme
Important PMH for bleeding CUSHINGPID
C – Cataracts
U – Ulcers
S – Striae, Skin thinning
H – Hypertension, Hirsutism
I – Immunosuppression, Infections
N – Necrosis of femoral heads
G – Glucose elevation
O – Osteoporosis, Obesity
I – Impaired wound healing
D – Depression/mood changes
What does melaena indicate
(indicatingUGI bleed, which has been digested and excreted,of sufficient volume to alter stool composition)
When are red cells considered in a resus situation?
When 30% of circulating volume lost
When do yuo give fresh frozen plasma in a bleed?
Fibrinogen <1g/L
or
PT/INR ir APTT >1.5 x normal
When give platelets in resus
If actively bleeding and platelets under 50 x109/L
What do you give to ppl on warfarin who are actively bleeding?
Prothrombin complex concentrate
Variceal bleed treatements
oesophageal = band ligation
Gastric - N-butyl-2-cryanoacrylate for gastric varices
Transjugular intrahepatic portosystemic shints - TIPS offered if bleeding uncontrolled from above
Causes of upper GI bleed
Peptic ulcer
Mucosal inflammation - oeoph, gast, duodenitis
Oesophageal varices
Mallory weiss tear
Gastric carcinoma
Coagulation disorders eg thrombocytopenia, warfarin
What do subcutaneous emphysema and vomitting suggest?
Oesophageal perfoartion - Boerhaave syndrome
What score do you use at first assessment vs endoscopy for upper GI bleed?
Blatchford - 1st assess
Rockall score - endoscipy after
What tdoes the Blatchford score calculate?
Higher scores (0-23) correspond with increased acuity and mortality
Admission risk markers counted in Baltchford score
Blood urea
Hb men or women
Systolic BP
Other markers - pulse, melaena, syncope, hepatic disease, HF
