GI Bleeding

Question 1

Common / important causes of a lower GI bleed?

Answer 1

• Rectal: haemorrhoids, fissure
• Diverticulitis
• Neoplasm

Question 2

Other causes of lower GI bleeds?

Answer 2

• IBD
• Infection: shigella, campylobacter, c. difficile
• Polyps
• Large upper GI bleed
• Angio: dysplasia, ischaemic colitis, HHT

Question 3

Investigations which should be performed for a suspected lower GI bleed?

Answer 3

• FBC, U&Es, LFTs, x-match, clotting, amylase
• Miicroscopy, culture, sensitivities of stool
• Imaging
  
  • AXR, erect CXR
  • Red cell scan
• Endoscopy
  
  1. Flex sigmoidoscopy
  2. OGD
  3. Colonscopy (difficult in major bleeding)

Question 4

Describe the management of a lower GI bleed?

Answer 4

• Resuscitate
• Urinary catheter
• Antibiotics if evidence of sepsis/perforation
• PPI if cause is potentially upper GI bleed
• Keep bed bound
  
  • (need to pass stool may be a large bleed => collapse)
• Stool chart
• Keep on clear fluids
  
  • (incase colonscopy required)

Question 5

When would surgery be required for a lower GI bleed?

Answer 5

If unremitting, massive bleed

Question 6

Common causes of upper GI bleeding?

Answer 6

• Peptic ulcer disease
• Acute erosions/gastritis
• Mallory-Weiss tear
• Varices
• Oesophagitis
• Stomach / oesophagus cancer

Question 7

Name a risk stratification score for upper GI bleeds?

Answer 7

• Rockall Score
  
  • Predicts re-bleeding and mortality
  • 40% of re-bleeders die
• Initial score of >=3 or final score >6 is indication for surgery

Question 8

Describe the components of the Rockall score?

Answer 8

• Initial score pre-endoscopy
  
  • Age
  • Shock: BP, pulse
  • Comorbidities
• Final score post-endoscopy
  
  • Final diagnosis + evidence of recent haemorrhage
    
    • Active bleeding
    • Visible vessel
    • Adherent clot

Question 9

Describe Oesophageal varices?

Answer 9

• Portal HTN -> dilated veins at sites of porto-systemic anastomosis
  
  • Left gastric and inferior oesophageal veins

Question 10

Name some causes of portal HTN?

Answer 10

• Pre-hepatic:
  
  • Portal vein thrombosis
• Hepatic:
  
  • Cirrhosis (commonest in UK), schistosomiasis (commonest worldwide), sarcoidosis
• Post-hepatic
  
  • Budd-Chiari, RHF, constrictive pericarditis

Question 11

Describe the prevention of bleeding from oesophageal varices?

Answer 11

• 1st line
  
  • beta blockers, repeat endoscopic banding
• 2nd line
  
  • beta blockers, repeat endoscopic banding, TIPSS

Question 12

Describe TIPSS?

Answer 12

• Trans-jugular intrahepatic poro-systemic shunt
• Artificial channel between hepatic vein and portal vein
  
  • => decreased portal pressure
• Colapinto needle creates tract through liver parenchyma which is expanded using a balloon and maintained by a stent
• Used when endoscopic therapy cannot control variceal bleeding

Question 13

What are the indications for surgery in an upper GI bleed?

Answer 13

• Re-bleeding
• Bleeding respite transfusing 6 units
• Uncontrollable bleeding at endoscopy
• Intial Rockall score>=3 or final score >6

Question 14

Management of upper GI bleeding

Answer 14

Question 15

What drug can be used to manage a variceal bleed?

Answer 15

• Terlipressin IV
  
  • Splanchnic vasopressor
  • Causes vasoconstriction of splanchnic circulation causing reduction in portal pressure

Question 16

Most common cause of an upper GI bleed?

Answer 16

Peptic ulcer disease

Question 17

Most common cause of a major lower GI bleed?

Answer 17

Diverticular disease

Question 18

Describe the aims of endoscopic treatment of upper gI bleeds?

Answer 18

• Locate the bleed locatioh
• Arrest the bleed
• Prevent recurrence

Question 19

What is second line for identifying upper GI bleeds?

Answer 19

• CT angiography
  
  • Limited to only detecting bleeds more than 1mL/min

Question 20

What are the options for locating lower GI bleeds?

Answer 20

• CT angiography
  
  • Can only locate > 1mL/min bleeds
• Intra-arterial angiography
  
  • Can locate bleed and allow embolisation using gel foam
• Colonscopy