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GI bleeding Flashcards

1
Q

What signs should be recognised as potential upper GI bleed

A

Haematemesis
Coffee ground vomit
Melana

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2
Q

Resus for upper GI bleed management. When transfuse?

A

NEWS
IV crystalloid
Transfuse if Hb below 70g/L. (aim for 70-100)

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3
Q

What do you use to risk assess an upper GI bleed?

A

Glasgow Blatchford Score

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4
Q

What should you give if sus varices

A

Terlipressin 2mg IV
Antibiotics as trust protocol
Continue aspirin
Suspend other antithrombotics

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5
Q

What investgiation should refer to and when with upper GI bleed?

A

Endoscopy in 24 hours of presentation
GI specialist if require therapeutic endoscopy

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6
Q

When should you activate major haemorrhage protocol and critical care review?

A

Haemodynamic instability

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7
Q

What landmark sperates upper and lower sources of GI bleeding?

A

Ligament of Treitz (suspensory ligament of the duodenum, suspends the duodejejunal flexure form the retroperitoneum)

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8
Q

How does bleeding above vs below the ligament of Treitz present?

A

Above -> haematemesis or melana
Below -> haematachazia (passing blood)

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9
Q

What is melaena?

A

Dark, black and tarry stool
Strong odour - digestion of haemoglobin

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10
Q

How to differentiate between iron induced black stool and melaena?

A

Iron will have a green tinge when spread thinner, melaena wont

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11
Q

Common causes of upper GI bleed list

A

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)

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12
Q

Symptoms of Mallory Weiss syndrome

A
  • Emesis
  • Retching
  • Coughing prior to haematemesis
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13
Q

Signs that indicate variceal bleed

A

jaundice
Ascites

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14
Q

Which peptic ulcer pain is relieved by eating?

A

Duodenal

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15
Q

Why is duodenal ulcer pain relieved by food?

A

Presence of food in the stomach triggers release of digestive juices which are alkaline and relieve the acidic pH

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16
Q

If the patient complains of pain when they eat which ulcer is it more likely t be?

A

Gastric

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17
Q

Symptoms peptic ulcer

A

Dyspepsia
Central burning chest pain

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18
Q

Signs of malignancy causing upper GI bleed

A
  • Dysphagia
  • early satiety
  • Cachexia
  • Involuntary weight loss
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19
Q

When is haematachezia seen with an upper GI bleed

A

When the bleed is massive

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20
Q

Why can upper GI bleeds be associated with orthostatic hypotension

A

When they are big enough to cause haemodynamic instability

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21
Q

History questions ass symptoms with upper GI bleed

A

painless vs. painful
trouble swallowing
unintentional weight loss
preceding emesis or retching
change in bowel habits

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22
Q

Symptoms of an oesophageal ulcer

A

Odynophagia, GORD, dysphagia

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23
Q

What is important to consider in a patient with a history of AAA or aortic graft with an upper GI bleed?

A

Aorto-eneteric fistula - abnormal connection between the aorta and the blood supply to the GI tract

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24
Q

What is angiodysplasia and how diagnosed

A

an abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract.
Diagnosed with colonoscopy or angiography

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25
What PMH is important when considering an angiodysplasia?
Renal disease Aortic stenosis Hereditary haemorrhagic telangiectasia
26
What are risk factors for peptic ulcer diseas?
H.pylori infection Smoking NSAID use Antithrombotic use
27
What should you especially consider if H.pylori infection, exccess alcohol and smoking are in the history?
Malignancy Peptic ulcer disease
28
What could cause upper GI bleed in a patient with gastroenteric anastomosis
Marginal ulcers - ulcers at an anastomic site
29
What conditions can cause overload in rigorous fluid resus?
CKD, HF
30
What patients is anaemia especially dangerous in?
IHD
31
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
32
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
33
Why is urea sometimes eleated in upper GI bleed?
Proteins in blood absorbed in GI tract and transported to kidney - increased waste product
34
What does a low MCV suggest about the casue of a bleed?
Iron deficiency anaemia, chronic bleeding
35
Differentials for an upper GI bleed
Peptic ulcer disease GE varices Upper GI cancers - oesophageal, gastric Erosive oesophagitis/gastritis/duodenitis Mallory Weiss tear
36
Causes of haemotachezia
Diverticulitis Colitis: -IBD - Crohns, UC. -Ishcaemic -Infective, C.difficile Colorectal cancers Haemorrhoids Anal fissure
37
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.
38
What diagnosis would be most likely in a young patient with diarrhoea, mucus in stool ad haematochezia?
IBD Get travel history
39
What diagnosis would be most likely in a older patient with L iliac fossa pain and haemotachezia?
Diverticulitis
40
What sort of vimtting is seen in a Mallory-Weiss tear?
Profuse with no blood initially then streaks of fresh blood
41
What does jaundice and haematemesis signal?
Oesophageal varices rupotured
42
What diagnosis does dyspepsia nad coffee ground vomit suggest?
Peptic ulcer disease
43
What symptoms make infective colitis/dysentry like;ly?
Fevers, bloating, acute D/V, unusualy food and heamatochezia, recent travel
44
Main symptoms of haemorrhoids
Tenesmus, perianal itch and constipation with heamatochezia
45
What is proctalgia?
Pain around anus/rectum
46
What symptoms make an anal fissure more likely?
Constipation Blood on wiping after passing stoll Proctalgia
47
What bacteria may be implicated in haemolytic uraemic syndrome?
E.Coli O157
48
What orgnaism is teh most common cause of bloody diarrhorea?
Shigella dysentriae
49
What is the most common cause of gastroenteritis?
Norovirus. Blood noy normally present
50
What does Shigella dysentriae cause?
Severe inflammation and necrosis in colon epithelium
51
What is Giardia Lamblia?
Parasitic infection causing malabsorption, abdominal pain, bloating and diarrhoea with steatorrhea
52
What are large volume GI bleeds more likely to be?
varices, peptic ulcer disease, diverticulitis, colitis.
53
What does H.pylori increase your risk of?
Peptic ulcer disease Gastic cnacer
54
Why are IBD patients at a higher risk of cancer
Chronic intestinal inflammation Immunosupression
55
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
56
What is alendronate
A Bisphosphonate
57
Which inherited condition increases the risk of a variety of cnacers?
HNPCC hereditary non polyposis colorectal cancer
58
Why do polyunsaturated fats increase you risk of cancer?
Increased cholesterol secretions which are broken down into potential carcinogens in GI tract
59
WHich GI conditions does smoking increase the risk of?
PUD GI cancer Flares of Crohns
60
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
61
What score is used to assess upper GI bleeding?
Rockall score
62
Features of the rockall socre
Age, shock, comorbidity, diagnosis (eg MW tear = o, GI malignancy - 2) Evidence of bleeding
63
What score strratifies high and low risk upper GI bleeds?
Glasgow-Blatchford bleeding score. Any risk higher than 0 needs intervention
64
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
65
What GI condition can CVS issues predispose to?
Ischaemic colitis
66
How does ischaemic colitis cause metabolic acidosis?
Raises lactate levels
67
Evidence of diverticulits on CT
Thickening of bowel wall Enhancement of colonic wall Dark spot at centre=diverticula
68
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.
69
Most common cause of bloody diarrhoea?
Shigella dysentriae
70
Initial management GI bleed
Ensure good IV access - 2 green venflows minimum
71
Criteria for central line insertion
Severe shock Rebleeding Severe comorbidity ehere CVP monitoring adventageous eg cardiac or renal failure Difficult/poor peripheral access
72
What Rockall score is mod to severe risk?
3-7
73
What rockall score is mild to mod risk?
0 -2
74
Factors Rockall score
Age - <60, 60-79, >79 Stigmata of shock - tachy, hypotension <100 Co-morbidity - IHD/CVA/COPD, renal/liver failure, disseminated mailgnancy
75
What is the Glasgow blathcford score?
For bleeding Blood urea Haemoglobin for men or women other markers = pulse, melaena, syncope, hepatic disease, cardiac failure
76
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
77
Bleeding disorders family history
Von Willebrands disease Haemophilia A Factor V leiden Antiphospholipid syndrome
78
Hereditary family bowel conditions
Herediatry non-polyposis colorectal cancer Familial adenomatous polyposis
79
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
80
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
81
What does melaena indicate
(indicating UGI bleed, which has been digested and excreted, of sufficient volume to alter stool composition)
82
When are red cells considered in a resus situation?
When 30% of circulating volume lost
83
When do yuo give fresh frozen plasma in a bleed?
Fibrinogen <1g/L or PT/INR ir APTT >1.5 x normal
84
When give platelets in resus
If actively bleeding and platelets under 50 x109/L
85
What do you give to ppl on warfarin who are actively bleeding?
Prothrombin complex concentrate
86
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
87
Causes of upper GI bleed
Peptic ulcer Mucosal inflammation - oeoph, gast, duodenitis Oesophageal varices Mallory weiss tear Gastric carcinoma Coagulation disorders eg thrombocytopenia, warfarin
88
What do subcutaneous emphysema and vomitting suggest?
Oesophageal perfoartion - Boerhaave syndrome
89
What score do you use at first assessment vs endoscopy for upper GI bleed?
Blatchford - 1st assess Rockall score - endoscipy after
90
What tdoes the Blatchford score calculate?
Higher scores (0-23) correspond with increased acuity and mortality
91
Admission risk markers counted in Baltchford score
Blood urea Hb men or women Systolic BP Other markers - pulse, melaena, syncope, hepatic disease, HF

GI, liver, kidney (50 decks)

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