GI Bleeding Flashcards
Causes of upper GI bleed…
Common causes: -Peptic ulceration -Oesophagitis/ gastritis -Mallory-Weiss tear -Oesophageal varices -Gastric carcinoma -Coagulopathies (warfarin, thrombocytopenia) Rare causes: aorto-enteric fistula, EDS
Main symptoms of upper GI bleed…
- Haematamesis (vomiting FRESH red blood)
- Coffee ground vomit (bleeding has ceased)
- Melaena (passage of black tarry stools)
How is the risk of death in upper GI bleeds identified?
Rockall Score - score of points depending on patient age, likelihood of shock and comorbidities .
Taken both before and after endoscopy
Urgent endoscopy is required for…
Anyone who scores >0 Rockall score, and high Blatchford score.
Unstable patients need resuscitation after which they need endoscopy ASAP - more stable patients need endoscopy within 24 hrs.
What is the treatment of moderate/ severe haemorrhage?
A-E assessment:
- Secure airway
- Oxygen for Spo2% of 94-98
- Two large bore cannulae
- IV fluid challenge - followed by blood when required
- Give Vit K/ clotting factors with fresh frozen plasma
- Monitor urine output (as part of volume status)
Key things to ask in history of upper GI bleed…
- Underlying disease e.g. dyspepsia, cancer, liver failure
- Previous occurrences
- Medications e.g. NSAIDs, steroids, anti-coagulants
- Alcohol intake
- Previous surgery
What score is used to determine who should have endoscopy?
Blatchford score -undertaken at admission.
Looks at: blood urea, Hb, systolic BP, other markers (pulse, melaena, syncope, hepatic disease, cardiac failure)
Management of upper GI bleed due to varices…
- Begin fluid resuscitation
- Give IV terlipressin 2mg every 4-6 hrs
- Antibiotic prophylaxis is important - ciprofloxacin
- Check INR - if prolonged, give IV vit K
- Early endoscopy is essential - balloon tamponade or variceal band ligation (VBL)
Management non-variceal upper GI bleed…
- Endoscopy is still very important - endoscopic therapy includes clips/ thermal coagulation with adrenaline
- H. pylori eradication where indicated
- IV PPI for 72hrs, then oral PPI 4-8 weeks - if indicated
- Repeat endoscopy 6-8 weeks later
What should be considered when variceal bleeding has not been controlled by band ligation?
Transjugular intrahepatic portosystemic shunts (TIPS)
PR bleeding can present in two ways…
- Melaena: black, tarry stools - usually due to UGI bleed but can be caused by bleeds in R colon/ small intestine
- Haematochezia: fresh, bright red rectal bleeding
Differentials of lower GI bleeds…
- Anorectal= anal fissures, haemorrhoids, anal prolapse
- Colonic= polyps, diverticular disease, colitis, colorectal cancer
- Massive UGI bleed
History of LGI bleed should include…
- Nature of bleed (melaena, haemtochezia, bloody diarrhoea)
- Associated sx - abdominal pain?
- Syncope - hypovolaemia
- Past medical history - IBD, peptic ulcer disease
- Change in bowel habit, weight loss - colonic Ca.
Assessment of LGI bleeding…
A-E assessment:
- Optimise airway and breathing as necessary
- IV access: two wide bore cannulae
- Blood from cannula (FBC, U+Es, LFTs, glucose, coagulation, group and save)
- Fluid resuscitate if necessary (250 0.9% NaCl boluses)
- Cross match 4-8 units of blood where necessary
Management of LGI bleeding…
- Clinical assessment (Obs and DRE) - calculate shock index (HR/SBP)
Shock index> 1 = unstable bleed:
- CT angiogram –> positive= interventional radiology or endoscopic
–>negative= book in for LGI endoscopy +/- UGI endoscopy, then treat if lesion is found.
Shock index <1 = stable bleed:
- Calculate risk score (major/minor) —> major= book in for LGI endoscopy +/- UGI endoscopy, then treat if lesion is found.
–>minor= discharge and arrange O/P investigation
