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GI bleeding Flashcards

1
Q

What is haematemesis?

A

Vomiting blood

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2
Q

What is malaena?

A

Black stools

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3
Q

What are causes of maleana?

A

GI haemorrhage/bleed

  • Peptic ulcer disease
  • Oesophageal varices
  • Oesophagitis
  • Gastritis
  • Mallory–Weiss tear
  • Neoplasm
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4
Q

What is the mechanism behind malaena?

A

Bleeding from any cause in the upper gastrointestinal tract can result in melaena. It is often said that bleeding must begin above the ligament of Treitz; however, this is not always the case.

The black, foul-smelling nature of the stool is due to the oxidation of iron from the haemoglobin, as it passes through the gastrointestinal tract.

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5
Q

What are common causes of upper GI bleeding?

A
  • Peptic ulcers
  • Mallory-Weiss tears
  • Oesophageal varcies
  • Gastritis/Gastric ulcers
  • Drugs
  • Oesophagitis
  • Duodenitis
  • Malignancy
  • No Obvious cause
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6
Q

What drugs can cause upper GI bleeding?

A
  • NSAIDs
  • Aspirin
  • Steroids
  • Thrombolytics
  • Anticoagulants
  • Alcohol
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7
Q

What would you want to ask someone who was presenting with features of an upper GI bleed?

A
  • Past GI bleeds
  • Dyspespsia/known ulcers
  • Known liver disease/oesophageal varices
  • Dysphagia
  • Vomiting
  • Weight loss
  • Drugs and alcohol use
  • Serious comorbidities - CVS, Resp, hepatic/renal, malignancy
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8
Q

What symptoms can occur in an acute upper GI bleed?

A
  • Haematemesis
  • Malaenia
  • Dizziness/Psotural Syncope
  • Abdo pain
  • Dysphagia
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9
Q

What signs might indicate someone is having an upper GI bleed?

A
  1. Signs of liver disease - telangiectasia, purpura, jaundice
  2. Signs of shock
  • Hypotension (SBP <100mmHg)/Postural drop >20 mmHg
  • Tacycardia
  • Decreased JVP
  • Decreased Urine output
  • CRT>2s
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10
Q

What bloods would you perform if someone presented with upper GI bleed, and why would you perform each?

A
  • FBC - blood loss
  • U+E’s - increased urea
  • Clotting - coagulopathy of liver disease
  • Glucose
  • LFTs - varices risk
  • Crossmatch/G+S - large bleed
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11
Q

Why would you consider putting in a CVP monitor in someone recieving blood transfusion for an acute GI bleed?

A

To assess transfusion adequacy and overload on the heart

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12
Q

When would you consider transfusion in someone with an upper GI bleed?

A
  • Haemoglobin <80 g/L
  • Patients with active bleeding
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13
Q

What drugs would you want to check for (and stop) in someone having an acute GI bleed?

A
  • NSAID’s
  • Aspirin
  • Clopidogrel
  • Warfarin
  • Consider stopping drugs masking shock features - B-blockers, antiarrythmia, anti-hypertensives
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14
Q

What can cause Mallory-Weiss tears?

A

Sudden inicrease in intra-abdominal pressure

  • Heavy coughing
  • Heavy wretching/dry heaves
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15
Q

How would you manage a varcieal upper GI bleed?

A
  • IV Terlipressin - give before endotherapy
  • Prophylactic Broad-spectrum IV antibiotics
  • Endotherapy - variceal ligation/Sclerotherapy
  • Consider balloon tamponade
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16
Q

What can be used to control uncontrolled variceal bleeding?

A
  • Trans-jugular intrahepatic porto-systemic shunt (TIPS)
  • Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
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17
Q

How would you manage bleeding ulcers?

A
  • Haemostatic therapy - 2 out of 3/3 out of 3 of clips, cautery or adrenaline
  • Post endoscopic PPI’s
  • Consider H. Pylori erdication therapy
  • Discontinue causative therapies - NSAIDs, aspirin
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18
Q

What scoring systems are used to stratify Upper GI bleeds?

A
  • Glasgow-Blatchford bleeding score - initial risk assessment of acute upper GI bleed
  • Rockall score - identify patients at risk of complications following acute upper GI bleed
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19
Q

What is coffee-ground vomit suggestive of?

A

Slow, intermittent bleed

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20
Q

What is regarded as the point which distinguishes an upper GI bleed from a lower GI bleed?

A

Ligament of trietz

21
Q

Which does coffee-ground vomit indicate as a cause of haematemesis; peptic ulcers or variceal bleeding?

A

Peptic ulcers

22
Q

What would brisk haematemesis be indicative of as a cause?

A
  • Variceal bleeding
  • Actively bleeding gastro-duodenal ulcer
23
Q

What is haematochezia most commonly associated with; UGIB or LGIB?

A

LGIB - but can be upper in severe UGIB

24
Q

Why might urea be raised in an upper GI bleed?

A

As blood passes through the small bowel and is partially digested, it can result in an elevated urea and urea/Cr ratio - equivalent to a large protein meal

25
What proportion of oesophageal varices will rebleed in a year?
60%
26
What are the major causes of lower GI tract bleeding?
* **Diverticular disease** * **Ischaemic colitis** * **Neoplasia** * **Haemorrhoids** * **Angiodysplasia**
27
What are causes of lower GI bleeding?
* **Diverticulitis** * **Colonic carcinoma** * **Meckel's Diverticulum** * **Ischaemic colitis** * **Polyps** * **Crohn's/Colitis** * **Haemorrhoids** * **Anal fissure** * **Angiodysplasia**
28
What is angiodysplasia?
Small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. It resembles telangiectasia and development is related to age and strain on the bowel wall. It is a degenerative lesion, acquired, probably resulting from chronic and intermittent contraction of the colon that is obstructing the venous drainage of the mucosa
29
What is haematochezia?
Bright red blood in the stool
30
What is haematochezia indicative of in terms of location of a GI bleed?
Lower GI bleed
31
What investigations would you consider doing in someone presenting with features of a lower GI bleed?
* **Examination + PR** * **Bloods** - FBC, U+E's, LFT's, Coagulation, Crossmatch/group and save * **Consider colonoscopu/sigmoidoscopy/Proctoscopy** * **Consider CT angiography** * **Consider Capsule endoscopy**
32
If you were performing protoscopy on someone with features of LGIB, what might you be looking for?
* **Haemorrhoids** * **Anorectal disease**
33
What would you be looking for on sigmoidoscopy/colonoscopy in someone with LGIB?
* **Inflammatory bowel disease** * **Cancer** * **Ischaemic colitis** * **Diverticular disease** * **Angiodysplasia**
34
How does chronic GI bleeding tend to present?
Iron Deficiency anaemia
35
What investigations would you consider doing in the context of chronic GI bleeding?
* **Upper GI endoscopy** * **Colonoscopy** * **CT colonography/Unprepaired CT**
36
What mnemonic can be used to remember causes of Haematemesis?
GUM BLEEDING * **G**astritis * **U**lcer (peptic) * **M**allory-Weiss (tear of the lower oesophageal mucosa) * **B**iliary (haemobilia – post cholecystectomy/liver biopsy) * **L**arge varices * **E**sophagitis (Oesophagitis) * **E**ntero-aortic fistula (after repair of aortic aneurysm) * **D**uodenitis (peptic ulcer) * **I**nflammatory bowel disease (rare) * **N**eovascularisation (rare) * **G**astric carcinoma (unusual)
37
What assessment/investigations would you consider doing in someone with features of a GI bleed?
* **Examination** * **Bedside** - NEWS, urine output * **Bloods** - FBC, U+Es, LFTs, Clotting, glucose, G&S/crossmatch * **CXR/AXR** * **OGD**
38
How would you immediately manage an acute GI bleed?
ABCDE * **2 wide bore cannulas** * **IV fluid resus** - consider major haemorrhage activation Following ABCDE * **Keep NBM** * **Correct clotting abnormalities** * **Stop antiplatelet/anticoagulant** * **Specific Manage based on cause** - Variceal vs non-variceal * **Treat any concurrent issues** e.g. encephalopathy, alcohol withdrawal
39
When would you consider givig a platelet transfusion in someone with an upper GI bleed?
Platelets \< 50x109
40
How does terlepressin work in a GI bleed?
Spanchnic vasoconstrictor that reduces portal blood flow
41
What would you give someone on warfarin who was having an upper GI bleed?
Vitamin K + prothrombin complex
42
What wuld you give someone who was on a DOAC who was having an upper GI bleed?
* **Praxibind** - dabigatran * **Prothrombin complex** - others
43
How would you manage someone who was coagulopathic for reasons other than low platelets, warfarin or doac therapy?
Vit K +/- FFP
44
What would you treat a low fibrinogen with in someone with a GI bleed?
Cryoprecipitate
45
How would specifically manage a non-varcieal bleed?
* **Endoscopic intervention** * Adrenaline injection to peptic ulcer * **Pharmacological** * IV PPI after endoscopy * Consider other therapy e.g. tranexamic acid
46
What is the glasgow-blatchford score?
Score system which can assess likelihood patient will need intervention during endoscopy (pre-endoscopy test)
47
What is the rockall score?
Mortality risk assessment post-endoscopy
48
How would you manage variceal bleeding post-intervention to prevent further bleeding?
* **Propranalol** * **Variceal banding** * **TIPSS** * **Liver transplant**
49
Why is TIPSS used to prevent further variceal bleeding?
Allows blood to flow out of the portal system into a hepatic vein

GI and General surgery (44 decks)

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