GI Bleeding Flashcards
Cases of GI Haemorrhages a year
8/10,000
Signs of a GI Haemorrhage
HMS HO
H - Haematemesis
M - Melaena
S - Syncope and blood loss
H - Haematochezia
O - Occult, iron deficiency
After what time in the gut does blood turn into melaena
>14 hours
Where would the bleeding have to be in the gut to get melaena?
Proximal colon/Upper GI
If upper GI negative examine proximal colon
Where would you have to have bleeding for Haematochezia to occur?
Lower GI
CASE:
67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission
PMH
15 year history of rheumatoid arthritis
Angina on exertion.
Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN
What do you need to know from the history?
Previous episodes
Previous surgery eg for PU (peptic ulcer) disease
Known varices or chronic liver disease
h/o dyspepsia, abdo pain, vomiting
Associated conditions: cirrhosis
malignancy
IBD etc
Family history: of bleeding conditions
Drug history: aspirin/ NSAIDs
H2receptor antagonists
Proton pump inhibitors
Warfarin
Alcohol / smoking history
CASE:
67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission
PMH
15 year history of rheumatoid arthritis
Angina on exertion.
Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN
What would you look for on examination?
BP, Pulse
Stigmata of chronic liver disease
Lymphadenopathy
Abdo mass or tenderness
Hepatomegaly/ splenomegaly
PR
Hereditary haemorrhagic telangiectasia (HHT)
- Genetic Vessel forming condition
Acanthosis nigricans – darker skin in patches
CASE:
67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission
PMH
15 year history of rheumatoid arthritis
Angina on exertion.
Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN
How are you going to treat her in A+E?
“replace vascular volume as fast as it was lost”
Large venflons
CVP line if: hypotensive >60 years old
rebleed going to theatre
>4 units transfusion
Haemaccel, gelofusine ; packed cells
O2
Check Hb*
clotting screen
X-match
U+E
*don’t forget Hb may be normal after a rapid bleed if haemodilution has not occurred
Monitor:
BP: keep systolic >100mmHg
CVP: 5-10 cm H2O
Urine output: >1ml/Kg/hr
Hb: >10g/dl
Platelets; clotting; Ca++: correct if necessary
CASE:
67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission
PMH
15 year history of rheumatoid arthritis
Angina on exertion.
Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN
What investigations would you arrange?
Postural hypotension (>15mmHg fall)
Tachycardia (>100) = blood vol loss
Vasoconstriction 5 – 10%
Recumbent hypotension
(<100mmHg) = blood loss vol
Shock 30%+
Check Hb*
clotting screen
X-match
U+E
*don’t forget Hb may be normal after a rapid bleed if haemodilution has not occurred
BP: keep systolic >100mmHg
CVP: 5-10 cm H2O
Urine output: >1ml/Kg/hr
Hb: >10g/dl
Platelets; clotting; Ca++: correct if necessary
How do you asses the risk of GI Haemorrhage?
ROCKALL SCORE
Initial risk score final risk score
0 0.2% 0.0%
1 2.4% 0.0%
2 5.6% 0.2%
3 11.0% 2.9%
4 24.6% 5.3%
5 39.6% 10.8%
6 48.9% 17.3%
7 50.0% 27.0%
8+ 41.1%
Causes of upper GI Haemorrhage?
Peptic Ulcer 50%
DU 30%
GU 20%
Erosions 10-20%
Mallory weiss tear 5-10%
Varices 5-7%
Oesophagitis 5%
Cancer 4%
Stomal ulcer 3%
Rare, other 5%
Undiagnosed 5%
Hp eradication therapy
Proton pump inhibitor bd
+ 2 of 3 antibiotics
Amoxycillin 1g bd }
Metronidazole 400mg bd } 1 week
Clarithromycin 500mg bd }
About 85-90% eradication rate
Re-infection rate ~ 1%/ year
Haemostatic therapy of Peptic ulcer?
Coagulation
Injection
Laser therapy
Why does re bleeding after injection therapy occur for PU?
Occurs in 10-20%
Greatest risk in first 48 hours
Overt bleeding – haematemesis, melaena
BP and pulse
CVP
Hb >2g within 24 hours
If in doubt consider repeat endoscopy
Stigmata of Haemorrhage?
What is this?
When should you give a person with PU surgery?
Exsanguinating
Rebleeding
Continued active bleeding at endoscopy
Transfusion for volume replacement:
<60 yrs >8 units/ 24 hours
>12 units/ 48 hours
>60 yrs > 4 units/ 24 hours
Management plan for PU?
Pathogenesis of Oesophageal varices?
Up to 50% of patients with cirrhosis or previously documented varices and acute upper GI bleed are bleeding from a non-variceal source
therefore endoscopy required to determine site.
Mortality 40% with each episode
Overall mortality 60% at 2 years
Management of Oesophageal Varices?
Fluids (colloid) AVOID SALINE
Transfusion
Platelets and FFP
Vitamin K
lactulose
Sclerotherapy
Control of bleeding achieved in 70-95% of patients
Needs to be followed by banding or repeated sclerotherapy
30% will rebleed before varices have been obliterated
Once obliterated, in alcoholics, they probably do not recur if patients stops drinking
Both paravariceal and intravariceal injection techniques have been
recommended. Regardless of the location of the external puncture, the depth of
needle penetration may be difficult to control and may range from intravariceal
to submucosal, or into the muscular layer, the latter perhaps predisposing to
deeper ulceration (panel A). The preferred technique is for injections of 1 to 2
mL of sclerosant into the varix starting as distally in the esophagus as
possible (near or just below the esophageal-gastric junction) and in a
circumferential route. Injections are then repeated 2 to 5 cm more proximally
(panel B). The total volume of scleroscent should not exceed 20 mL per session,
above which rate the incidence of complications may increase. No particular
sclerosant has emerged as consistently superior (sodium tetradecyl, ethanolamine
oleate, absolute ethanol, and sodium morrhuate are agents available in the
What is a Variceal band ligation?
Endoscopic placement of bands around oesophageal varices.
Effective at stopping bleeding in ~90%
Needs to be repeated over weeks/months to obliterate varices
What is Vasopressin?
Reduces portal venous pressure
20u in 100ml 5% dextrose in 10 minutes
Or infuse 0.4u/min up to 2 hours
S/E: abdominal pain
facial pallor
coronary vasoconstriction
hepatic A blood flow liver necrosis
Name 2 Somatostatin analogues
octreotide
Terlipressin
Reduce portal pressure
but fewer side effects than vasopressin
What is a Sengstaken tube?
4 lumen tube
- Gastric balloon
- Oesophageal balloon
- Gastric aspiration
- Oesophageal aspiration
