GI Bleeding Flashcards
Upper GI bleed define
Proximal to ligament of Treitz
Features of upper GI bleed
Haematemesis = vomiting fresh/altered bleed Malaena = black tarry stools Haematochezia = fresh or altered blood PR
What is haematochezia a sign of
Large upper GI bleed
Lower GI bleed define
distal to ligament of Treitz
Features of lower GI bleeds
Malaena
Haematochezia
Causes of upper GI bleeds (most to least common)
Peptic ulcer (almost half!!) Then inflammation of oesophagus/stomach/duodenum Then varices Portal hypertensive gastropathy malignany Mallory Weiss tear Vascular malformation
Causes of lower GI bleeds (most to least common)
Diveritcular disease!! 1/3 Haemorrhoids Mesenteric ischaemia Colitis Cancer Rectal ulcers Angiodysplasia Radiation Drugs Other
Causes of peptic ulcer disease
H pylori
NSAIDs
Smoking
Alcohol
Symptoms of peptic ulcer disease
epigastric pain
nausea
early satiety
Complications of peptic ulcer disease
bleeding
perforation
Spectrum of peptic ulcer disease
Small
Larger punctured out
Large in antrum of stomach (distal) = poor gastric emptying via blockage
Completely through stomach wall and entered blood vessel = bleed/perforation
Causes of oesophagitis
GORD Medications Obesity Smoking Alcohol
Causes of gastritis and duodenitis
H pylori NSAIDs Smoking Alcohol Medications
Causes of varices
Portal HTN caused by
- liver cirrhosis commonest in UK
- venous occlusion/thrombus
- schistosomiasis commonest cause worldwide
Cause of Mallory Weiss Tear
Forceful vomiting/retching causing a mucosal tear in the oesophagus
History of Mallory Weiss tear
Tear and bleedings occurring typically after repeated bouts of vomiting
Diverticular bleed
Adjacent to mesenteric arterial blood flow
Due to decreased thickness of colonic wall so increased risk of bleeding
RF of diverticulae
?? Straining/constipation Muscle spasm low dietary fire genetics
Causes of haemorrhoids
Straining to have bowel movement Sitting for long periods of time Chronic constipation or diarrhoea Being overweight or obese Pregnancy
What are the stages of colonic cancer?
Polyps -> grow to dysplasia -> adenocarcinoma -> invasive cancer
RF for polyps
Age Overweight Smoker FH Polyposis syndromes
Colitis Causes
IBD
Ischaemic (distal transverse colon where SMA and IMA meet - watershed area)
Infective
NSAIDs
How to manage an Upper GI bleed
Hx Examination initial assessment How and when to refer for endoscopy Endoscopy therapy Post OGD management Discharge and follow up
What to ask about in Hx?
True haematemesis?
Melaena?
Systemic symptoms of blood loss?
RF of history of bleed = drugs, co-morbidities such as CKD/IHD/frailty/chronic liver disease
Systemic symptoms of blood loss?
Dizziness
Palpitations
Chest pain
SOB
Examination
A = if vomiting large volumes of blood may need intubation? B = RR and sats signs of blood loss, ABG?, CXR C = IV acess, fluids, blood products, monitor HR/BP D = AVPU assess consciousness E = abdominal exam to find a specific cause, rectal exam, signs of chronic liver disease
Splanchnic circulation
1.8L of flow through circulation per miute
20-40% of total blood volume
portal vein is a major reservoir
Class % loss of shock
1 = 10-15% 2 = 15-30% 3 = 3-40% 4 = >40%
What is the average circulating volume of blood of a 70kg man?
5L
Class 1 shock
10-15% loss
No clinical signs as physiological compensation
Class 2 shock
15-30% loss
Postural hypotension
Generalised vasoconstriction
Class 3 shock
30-40% loss
Hypotension
tachycardia >129
Tachypnoea
Class 4 shock
>40% loss Marked hypotension tachycardia tachypnoea Comatose
When restoring blood loss what is important to provide maximum flow?
Short wide tube
Poiseuille’s law of flow = 1/length to the power of 4
What is the recommendation in restoring blood in a GI bleed?
2 wide bore cannulae
large vein
(central line) = 18-14G
Cannulae colours and gauge
Red = 14G Grey = 16G White = 17G Green = 18G Pink = 20G Blue = 2G Yellow = 24G
Flow rates of different cannulae gauges
Red = 14G = 300ml/min Grey = 16G = 150ml/min Green = 18G = 75ml/min Pink = 20G = 40ml/min
benefit of rapid fluid resus
Fewer Mis and fewer deaths with rapid blood/fluid resus
Transfusion targets
Hb>80
If IHD = >100
If chronic liver disease >70
massive transfusion risks
fluid overload electrolyte/acid base disturbance transfusing products devoid of clotting factors = consider cryoprecipitate/FFP/platelets hypothermia iron overload if repeated transfusions
Blood tests for GI bleed
ABG FBC U&E LFTs Coagulation screen Group & Save compatible bloods for future
Platelet target
> 50
INR target
<1.5
Initial treatments
Anticoagulants hold or reverse anticoagulants to fix INR
PPI decrease lesions in some guidelines before endoscopy?
Tranexamic acid?? -
How to reverse warfarin?
Vitamin K
Discuss with haematologists = FFP/PPC
Variceal bleed specific treatment
Terlipressin 1-2mg QDS
If varices likely
Caution in IHD
(Seek expert help)
Prophylactic AB as systemic sepsis increases portal pressure and also treat any chest infection/aspiration which has develop
What is MOA of terlepressin?
(lysine vasopressin)
mesenteric/splanchnic vasoconstrictor
Decreases portal venous inflow
Which AB in variceal bleed?
Cephalosporin/quinolone/augmentin
Management post resuscitation?
Decide whether or not they need endoscopy and how urgent
Glasgow glatchford score use
To determine risk of patients having a re-bleed before endoscopy and after resus
Glasgow glatchford score outcomes
Score <2 = low risk upper GI bleed = consider OP endoscopy
>6 = 80% required endoscopic treatment
Glasgow glatchford score measurements
Blood urea Hb Systolic BP Pulse history/co-morbidities
Rockall Score Purpose
Risk of re-bleed post endoscopy and mortality
Endoscopic diagnosis used to calculate full score
What needs to be done/ready if there is an urgent endoscopy to be done?
- good IV access
- blood available
- normal BP and Hb>7
- under GA if agitated = better result and protects airways
Ulcers endoscopic management
Adrenaline injection = vasoconstriction so reduced flow to that area and local tamponade of those vessels
Clip = over ulcer to close edges and prevent further bleed
Diathermy therapy with probe
Powder through catheter through endoscope to promote clotting in area
Dosage of adrenaline in ulcers endoscopic tx
5-40mls
varices endoscopic treatment
Band ligation = scarring of vessel and obliteration
Injection sclerotherapy in gastric varices = inject glue so it scleroses and closes
Sengstaken Blakemore tube if others don’t work = compresses varices with 2 balloons, pass through mouth into stomach, inflate balloon with water/air
Indication for Sengstaken Blakemore tube
- patient already intubated
- other treatments don’t work in endoscopy
- under direct supervision with endoscopy
- experienced staff
Post endoscopy/medical therapy for ulcers
PPIs = healing of ulcer through increased clotting, Continuous infusion for 72 hours H pylori eradication therapy Repeat endoscopy (OGD) to ensure gastric ulcer healing in 6-8 weeks
Mechanism of PPI post endoscopy in clotting
PPI increase pH
Low pH activated pepsin which lyses clot and inactivates platelets
So PPI’s prevent this by making less pepsin
Success of PPI’s post endoscopy
Prevents re-bleeding
Prevents mortality
Reduces need for surgery
Why are PPIs not given to everyone?
cost? electrolyte disturbances Interactions Pneumonia Arrhythmias C. difficile Increased mortality in elderly
Post endoscopy/medical therapy for varices
Beta blockers
Sequential banding procedures
TIPSS procedure = allows blood flow in portal vein to go straight to systemic flow
Liver transplant
When is surgery and interventional radiology needed?
If endoscopy fails
Interventional radiology
CT angiogram to find it
Then Angiography to embolise vessels
Surgery indications
- uncontrolled further haemorrhage
- failed endoscopic treatment twice
Small bowel bleeding
- only 5% of cases
- angiodysplasia most common cause
- video capsule endoscopy (pill cam swallowed and takes images) to diagnose
- then tx = balloon enteroscopy
- other diagnostic methods = CT angio, interventional angio, red cell scan in rare cases
