GI Bleeding Flashcards
ligament of Treitz
thin band of tissue that supports the end of the duodenum and the beginning of the jejunum
GI bleeding above the ligament of treitz
malaena, blood in vomitus
GI bleeding below the ligament of treitz
fresh/altered blood
causes of upper GI bleed
duodenal ulcer
gastric ulcer
gastritis
varices
mallory-weiss
other less common causes
typical presentation of someone with duodenal ulceration
healthy
normal appetite
waking in the middle of the night with RUQ pain
pain relieved by food
other less common causes of upper GI bleeds
oesophagitis
duodenitis
tumour
dieulafoy
aortoduodenal fistula
typical presentation of someone with duodenal ulceration
healthy
normal appetite
waking in the middle of the night with RUQ pain
pain relieved by food
never malignant
typical presentation of someone with a gastric ulcer
thin/anaemic
afraid to eat
never pain at night
deep epigastric pain
pain on eating
vomiting eases pain
10% malignant
typical presentation of a mallory-weiss tear
male
alcohol intake
migraine/vertigo
initial vomit is normal, subsequent vomit creates haematemesis
90% settle
causes of oesophagitis
reflux
scalds
burns
infective
dieulafoy’s lesion
large tortuous arteriole most commonly in the stomach wall that bleeds
can present anywhere in the GI tract
causes of lower GI bleeding
ano rectal conditions eg. haemorrhoids, fissure, sepsis
inflammatory bowel disease
diverticular disease
malignancy
angiodysplasia
lower GI bleeding is 60% due to
ano rectal conditions eg. haemorrhoids, fissure, sepsis
angiodysplasia
abnormal tortous dilated small blood vessel in the mucosal wall and submucosal layers of the GI tract
difficult to diagnose
if an angiodysplasia lesion is detected
treatment with coagulation
diverticular disease
common
usually self limiting
may require surgery
management of upper Gi bleeding
Airways:remove clots from airways
Breathing:supplemental oxygen to assist breathing
Circulation:isotonic fluid
medical therapy for bleeding ulcer
IV PPI
eradicate helicobacter pylori
endoscopy
factors increasing likelihood of re-bleed after medical therapy of bleeding ulcer
patient factors: shock, ongoing bleeding, Hb > 10 on admission, age >60
ulcer factors: visible vessel, clot in base, active bleeding, black/red spots, left gastric or duodenal artery territory ulcer
surgery for bleeding ulcer
indicated if there is massive exsanguinating bleed or if there ia a rebelled in a person over 60
under-run or gastrectomy
difference between an under run and a gastrectomy
under-run is simple quick and safe
gastrectomy is a big operation which should be avoided
things on exam that indicate portal hypertension
ascites
umbilical hernia
hairless
distended veins
causes of portal hypertension
pre- hepatic: thrombosis of portal vein
hepatic: cirrhosis (90% of the time)
post-hepatic: budd-chiari thrombosis hepatic veins
medical management of varices
drugs
terlipressin
octreotide
balloon tamponade
Minnesota tube
minnesota tube
oesophageal balloon
gastric balloon
oesophageal channel
gastric channel
balloon tamponade
inserted mouth/nose
inflated <24 hours
Transjugular portasystemic shunt
A transjugular intrahepatic portosystemic shunt (TIPS) connects the portal vein to the hepatic vein
bypasses cirrhotic liver which causing blockage due to scar tissue which is the cause of the portal hypertension
management of lower GI bleeding
similar to upper GI
Airways: support if unconscious
Breathing:supplemental oxygen to assist breathing
Circulation:isotonic fluid
if lower GI bleed patient is stable
investigate with colonoscopy
+/- angiography if actively bleeding or red cell scan
treat underlying cause
if lower GI bleed patient is unstable
Aggressive resuscitation
Blood
Correct coagulation
CT angiogram to localise source of bleeding
emergency surgery - segmental resection if source localised
subtotal colectomy and end ileostomy if source not found
