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GI and Surgery > GI Bleeding > Flashcards

GI Bleeding Flashcards

1
Q

Are upper or lower GI bleeds more common?

A

Upper GI

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2
Q

Why are NSAIDs a risk factor for an upper GI bleed?

A

They inhibit prostaglandins synthesis which are gastroprotective, this leads to excessive HCl secretion and mucosal damage.

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3
Q

Why does urea rise in upper GI bleeds?

A

Blood in GI tract gets broken down by acid and digestive enzymes, urea is one of the breakdown products and is absorbed in the intestines.

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4
Q

Which drug would you use for the prophylaxis of oesophageal bleeding?

A

Propranolol

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5
Q

What is the most common cause of UGIB?

A

Peptic ulcer disease

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6
Q

Define UGIB

A

Upper GI bleed - bleeding from oesophagus, stomach or duodenum.

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7
Q

List the cause of UGIB

A

Peptic ulcer disease.
Gastritis.
Oesophageal varices.
Mallory-Weiss tear.
Oesophageal and gastric cancer.

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8
Q

What are oesophageal varices and why do they occur?

A

Abnormal, dilated veins at the lower end of oesophagus due to portal hypertension, secondary to chronic liver disease/cirrhosis.

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9
Q

What is a Mallory-Weiss tear?

A

Tear of mucous membrane at gastro-oesophageal junction or within gastric cardia.

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10
Q

What is the classical presentation of a Mallory-Weiss tear?

A

An episode of haematemesis followed by related episodes of vomiting.

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11
Q

List the risk factors for an UGIB

A

NSAIDs, anticoagulants, alcohol abuse, chronic liver disease, CKD, advancing age, Hx of peptic ulcer disease or H.pylori infection.

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12
Q

What are the clinical features of an UGIB?

A

Haematemesis, melaena, shock (tachycardia, hypotension).
Symptoms related to pathology e.g. epigastric pain and dyspepsia (peptic ulcer) or jaundice and ascites (liver disease causing varices).

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13
Q

What investigations for UGIB?

A

Upper GI endoscopy (within 24 hrs).
Bloods: FBC, U&Es, LFTs, clotting, group & save with cross match.

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14
Q

What are the 2 scoring systems used to assess risk of UGIB?

A

Glasgow-Blatchford score and Rockall score.

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15
Q

Which features does Glasgow-Blatchford score take into account?

A

Drop in Hb, rise in urea, BP, HR, melaena, syncopy.

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16
Q

When is the Rockall score used?

A

Post-endoscopy

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17
Q

Which features does Rockall score take into account?

A

Age.
BP and HR.
Co-morbidities.
Diagnosis (cause of bleeding).
Endoscopic stigmata of recent haemorrhage e.g. clots or bleeding vessels.

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18
Q

Briefly describe the management for an UGIB

A

ABCDE approach to resuscitation.
Bloods: FBC, U&Es, clotting, LFTs, cross match.
Access (2 large bore cannulas).
Transfuse: bloods, platelets, clotting factors (FFP).
Endoscopy (OGD): aspirate blood, intervention to stop bleeding e.g. banding or cauterisation.
Drugs (stop anticoagulants and NSAIDs).

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19
Q

When would you use prothrombin complex concentrate?

A

To reverse warfarin in patients taking it and actively bleeding.

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20
Q

How would you manage a variceal bleed?

A

Terlipressin, prophylactic broad spectrum antibiotics, variceal band ligation/stent/transjugular intrahepatic portosystemic shunts (TIPS).

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21
Q

What is the MOA of terlipressin?

A

ADH analogue —> splanchnic vasoconstriction —> reducing portal pressure.

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22
Q

What is a LGIB?

A

Lower GI bleed - bleeding distal to duodenum.

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23
Q

How would an acute LGIB present?

A

PR bleeding, +/- shock.

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24
Q

How would a chronic LGIB present?

A

Incidental finding - iron deficiency anaemia, positive FIT test.

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25
Q

What are the causes of acute LGIB?

A

Diverticulosis, haemorrhoids, fissures, fistulas, ischaemic colitis, angiodysplasia, polyps, colorectal carcinoma, IBD, infective (dysentery).

26
Q

What is the most common cause of LGIB?

A

Diverticulosis

27
Q

What are diverticula?

A

Sac-like protrusions of colonic mucosa through muscular wall.

28
Q

What are haemorrhoids?

A

Enlarged blood vessels in rectum/anus (enlarged anal vascular cushions).

29
Q

What are fissures?

A

Tears in anal mucosa.

30
Q

What are fistulas?

A

Abnormal connections between 2 epithelial surfaces.

31
Q

Define angiodysplasia

A

Abnormal, tortuous, dilates small blood vessels in mucosa and sub mucosa. Abnormal connections between artery and vein.

32
Q

Define polyp

A

Benign neoplastic proliferations of colonic epithelium.

33
Q

What investigations would you do for a suspected LGIB?

A

Bloods: FBC, U&Es, LTFs, clotting, group & save with cross match.
Digital rectal exam.
CT abdomen/pelvis.
CT angiography.
OGD endoscopy.
Colonoscopy.

34
Q

Why is a colonoscopy difficult to do in an emergency?

A

Due to faeces blocking colon.

35
Q

How would you manage a stable LGIB?

A

Minor: discharge & outpatient investigations.
Major: lower GI endoscopy.

36
Q

How would you manage an unstable LGIB/active bleed?

A

Urgent resuscitation: A to E approach, blood products.
Reversal of anticoagulants.
CT angiogram: embolisation or endoscopy techniques.

37
Q

When is surgical intervention required for a LGIB?

A

Ongoing GI bleeding with instability, where endoscopic & radiographic treatments have failed.

38
Q

Treatment for gastric varices?

A

Sclerotherapy or TIPS if bleeding not controlled.

39
Q

What is the Oakland score?

A

Used to predict risk of adverse outcomes for LGIB.

40
Q

Which factors does Oakland score take into account?

A

Age, gender, previous LGIB admission, DRE findings, HR, BP, Hb.

41
Q

Can acute UGIB present with PR bleeding?

A

Yes - because if the patient is bleeding really quickly and in shock, the blood can pass through the GI tract without the chance of it being digested (e.g. melaena).

42
Q

Investigations for iron deficiency anaemia in postmenopausal females and males with no history of significant overt non-GI blood loss?

A

Coeliac screen.
FIT test.
PR examination.
OGD endoscopy.
Lower GI endoscopy.

43
Q

What is used to stop an uncontrolled variceal haemorrhage?

A

Sengstaken-Blakemore tube

44
Q

What should be used to control a variceal bleed if other measures fail?

A

Transjugular Intrahepatic Portosystemic Shunt (TIPSS) - connects hepatic vein to portal vein.

45
Q

What is the Rockall score a measure of?

A

Percentage risk of rebleeding and mortality.

46
Q

What does Glasgow-Blatchford score measure?

A

Determines whether a patient will need to be admitted for medical intervention.

47
Q

What are the risk factors for haemorrhoids?

A

Constipation/straining, pregnancy, obesity, increased age and increased intra-abdominal pressure (weightlifting or chronic cough).

48
Q

Describe the classification for haemorrhoids

A

1st degree: no prolapse.
2nd degree: prolapse when straining and return on relaxing.
3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back.
4th degree: prolapsed permanently.

49
Q

Describe the symptoms of haemorrhoids

A

May be asymptomatic.
Painless, bright red rectal bleeding (on toilet tissue) that is not mixed with stool. May be associated with sore/itchy anus or lump around/inside anus.

50
Q

What are the differentials for rectal bleeding?

A

Haemorrhoids, anal fissures, diverticulosis, IBD, colorectal cancer.

51
Q

Name the topic treatments used for the symptomatic relief of haemorrhoids

A

Anusol (shrinks haemorrhoids – ‘astringents’).
Anusol HC (contains hydrocortisone – short term use).
Germoloids cream (contains lidocaine).
Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term use).

52
Q

Describe the non-surgical treatment of haemorrhoids

A

Rubber band ligation.
Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy).
Infra-red coagulation (infra-red light is applied to damage the blood supply).
Bipolar diathermy.

53
Q

Describe the surgical management of haemorrhoids

A

Haemorrhoidal artery ligation: using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply.
Haemorrhoidectomy: excising the haemorrhoid (may result in faecal incontinence).
Stapled haemorrhoidectomy: excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal.

54
Q

Name one complication of haemorrhoids

A

Thrombosed haemorrhoids - caused by strangulation at the base of the haemorrhoid, resulting in thrombosis in the haemorrhoid. They’re very painful, appearing as purplish, very tender, swollen lump around the anus.

55
Q

A 23-year-old man presents with a three week history of painless rectal bleeding. The bleeding typically occurs post defecation and blood is noted in the toilet pan and on paper when he wipes himself. He is otherwise well and his bowel habit is regular, though recently he has been slightly constipated.

A

Haemorrhoids

56
Q

34-year-old lady presents with a long history of chronic constipation and occasional episodic rectal bleeding. Abdominal examination is unremarkable, on digital rectal examination she has an indurated ulcer located anteriorly approximately 4cm from the dentate line.

A

Solitary rectal ulcer

57
Q

A 23-year-old lady presents with a one week history of painful rectal bleeding that typically occurs in association with the passage of the stool and is also noted on wiping the anus afterwards. Examination of the anorectum is impossible due to pain. However, external inspection reveals a midline sentinel skin tag.

A

Fissure in ano

58
Q

What is the first line treatment for a chronic anal fissure?

A

Topical GTN

59
Q

What is the strongest risk factor for anal cancer?

A

HPV infection

60
Q

Describe the management of an acute anal fissure

A

Soften stool, dietary fibre, analgesia and topical anaesthetic cream

GI and Surgery (14 decks)

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