GI Bleeding Flashcards
1
Q
Upper GI bleed define
A
Proximal to ligament of Treitz
2
Q
Features of upper GI bleed
A
Haematemesis = vomiting fresh/altered bleed Malaena = black tarry stools Haematochezia = fresh or altered blood PR
3
Q
What is haematochezia a sign of
A
Large upper GI bleed
4
Q
Lower GI bleed define
A
distal to ligament of Treitz
5
Q
Features of lower GI bleeds
A
Malaena
Haematochezia
6
Q
Causes of upper GI bleeds (most to least common)
A
Peptic ulcer (almost half!!) Then inflammation of oesophagus/stomach/duodenum Then varices Portal hypertensive gastropathy malignany Mallory Weiss tear Vascular malformation
7
Q
Causes of lower GI bleeds (most to least common)
A
Diveritcular disease!! 1/3 Haemorrhoids Mesenteric ischaemia Colitis Cancer Rectal ulcers Angiodysplasia Radiation Drugs Other
8
Q
Causes of peptic ulcer disease
A
H pylori
NSAIDs
Smoking
Alcohol
9
Q
Symptoms of peptic ulcer disease
A
epigastric pain
nausea
early satiety
10
Q
Complications of peptic ulcer disease
A
bleeding
perforation
11
Q
Spectrum of peptic ulcer disease
A
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
12
Q
Causes of oesophagitis
A
GORD Medications Obesity Smoking Alcohol
13
Q
Causes of gastritis and duodenitis
A
H pylori NSAIDs Smoking Alcohol Medications
14
Q
Causes of varices
A
Portal HTN caused by
- liver cirrhosis commonest in UK
- venous occlusion/thrombus
- schistosomiasis commonest cause worldwide
15
Q
Cause of Mallory Weiss Tear
A
Forceful vomiting/retching causing a mucosal tear in the oesophagus
16
Q
History of Mallory Weiss tear
A
Tear and bleedings occurring typically after repeated bouts of vomiting
17
Q
Diverticular bleed
A
Adjacent to mesenteric arterial blood flow
Due to decreased thickness of colonic wall so increased risk of bleeding
18
Q
RF of diverticulae
A
?? Straining/constipation Muscle spasm low dietary fire genetics
19
Q
Causes of haemorrhoids
A
Straining to have bowel movement Sitting for long periods of time Chronic constipation or diarrhoea Being overweight or obese Pregnancy
20
Q
What are the stages of colonic cancer?
A
Polyps -> grow to dysplasia -> adenocarcinoma -> invasive cancer
21
Q
RF for polyps
A
Age Overweight Smoker FH Polyposis syndromes
22
Q
Colitis Causes
A
IBD
Ischaemic (distal transverse colon where SMA and IMA meet - watershed area)
Infective
NSAIDs
23
Q
How to manage an Upper GI bleed
A
Hx Examination initial assessment How and when to refer for endoscopy Endoscopy therapy Post OGD management Discharge and follow up
24
Q
What to ask about in Hx?
A
True haematemesis?
Melaena?
Systemic symptoms of blood loss?
RF of history of bleed = drugs, co-morbidities such as CKD/IHD/frailty/chronic liver disease
25
Systemic symptoms of blood loss?
Dizziness
Palpitations
Chest pain
SOB
26
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
```
27
Splanchnic circulation
1.8L of flow through circulation per miute
20-40% of total blood volume
portal vein is a major reservoir
28
Class % loss of shock
```
1 = 10-15%
2 = 15-30%
3 = 3-40%
4 = >40%
```
29
What is the average circulating volume of blood of a 70kg man?
5L
30
Class 1 shock
10-15% loss
| No clinical signs as physiological compensation
31
Class 2 shock
15-30% loss
Postural hypotension
Generalised vasoconstriction
32
Class 3 shock
30-40% loss
Hypotension
tachycardia >129
Tachypnoea
33
Class 4 shock
```
>40% loss
Marked hypotension
tachycardia
tachypnoea
Comatose
```
34
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
35
What is the recommendation in restoring blood in a GI bleed?
2 wide bore cannulae
large vein
(central line) = 18-14G
36
Cannulae colours and gauge
```
Red = 14G
Grey = 16G
White = 17G
Green = 18G
Pink = 20G
Blue = 2G
Yellow = 24G
```
37
Flow rates of different cannulae gauges
```
Red = 14G = 300ml/min
Grey = 16G = 150ml/min
Green = 18G = 75ml/min
Pink = 20G = 40ml/min
```
38
benefit of rapid fluid resus
Fewer Mis and fewer deaths with rapid blood/fluid resus
39
Transfusion targets
Hb>80
If IHD = >100
If chronic liver disease >70
40
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
```
41
Blood tests for GI bleed
```
ABG
FBC
U&E
LFTs
Coagulation screen
Group & Save compatible bloods for future
```
42
Platelet target
>50
43
INR target
<1.5
44
Initial treatments
Anticoagulants hold or reverse anticoagulants to fix INR
PPI decrease lesions in some guidelines before endoscopy?
Tranexamic acid?? -
45
How to reverse warfarin?
Vitamin K
| Discuss with haematologists = FFP/PPC
46
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
47
What is MOA of terlepressin?
(lysine vasopressin)
mesenteric/splanchnic vasoconstrictor
Decreases portal venous inflow
48
Which AB in variceal bleed?
Cephalosporin/quinolone/augmentin
49
Management post resuscitation?
Decide whether or not they need endoscopy and how urgent
50
Glasgow glatchford score use
To determine risk of patients having a re-bleed before endoscopy and after resus
51
Glasgow glatchford score outcomes
Score <2 = low risk upper GI bleed = consider OP endoscopy
| >6 = 80% required endoscopic treatment
52
Glasgow glatchford score measurements
```
Blood urea
Hb
Systolic BP
Pulse
history/co-morbidities
```
53
Rockall Score Purpose
Risk of re-bleed post endoscopy and mortality
| Endoscopic diagnosis used to calculate full score
54
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
55
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
56
Dosage of adrenaline in ulcers endoscopic tx
5-40mls
57
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
58
Indication for Sengstaken Blakemore tube
- patient already intubated
- other treatments don't work in endoscopy
- under direct supervision with endoscopy
- experienced staff
59
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
```
60
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
61
Success of PPI's post endoscopy
Prevents re-bleeding
Prevents mortality
Reduces need for surgery
62
Why are PPIs not given to everyone?
```
cost?
electrolyte disturbances
Interactions
Pneumonia
Arrhythmias
C. difficile
Increased mortality in elderly
```
63
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
64
When is surgery and interventional radiology needed?
If endoscopy fails
65
Interventional radiology
CT angiogram to find it
| Then Angiography to embolise vessels
66
Surgery indications
- uncontrolled further haemorrhage
| - failed endoscopic treatment twice
67
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
