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MET3a > GI Bleeding > Flashcards

GI Bleeding Flashcards

1
Q

Upper GI bleed define

A

Proximal to ligament of Treitz

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2
Q

Features of upper GI bleed

A 
Haematemesis = vomiting fresh/altered bleed
Malaena = black tarry stools
Haematochezia = fresh or altered blood PR
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3
Q

What is haematochezia a sign of

A

Large upper GI bleed

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4
Q

Lower GI bleed define

A

distal to ligament of Treitz

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5
Q

Features of lower GI bleeds

A

Malaena

Haematochezia

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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
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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
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8
Q

Causes of peptic ulcer disease

A

H pylori
NSAIDs
Smoking
Alcohol

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9
Q

Symptoms of peptic ulcer disease

A

epigastric pain
nausea
early satiety

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10
Q

Complications of peptic ulcer disease

A

bleeding

perforation

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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

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12
Q

Causes of oesophagitis

A 
GORD
Medications
Obesity
Smoking
Alcohol
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13
Q

Causes of gastritis and duodenitis

A 
H pylori
NSAIDs
Smoking 
Alcohol
Medications
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14
Q

Causes of varices

A

Portal HTN caused by

  • liver cirrhosis commonest in UK
  • venous occlusion/thrombus
  • schistosomiasis commonest cause worldwide
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15
Q

Cause of Mallory Weiss Tear

A

Forceful vomiting/retching causing a mucosal tear in the oesophagus

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16
Q

History of Mallory Weiss tear

A

Tear and bleedings occurring typically after repeated bouts of vomiting

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17
Q

Diverticular bleed

A

Adjacent to mesenteric arterial blood flow

Due to decreased thickness of colonic wall so increased risk of bleeding

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18
Q

RF of diverticulae

A 
??
Straining/constipation
Muscle spasm
low dietary fire
genetics
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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
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20
Q

What are the stages of colonic cancer?

A

Polyps -> grow to dysplasia -> adenocarcinoma -> invasive cancer

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21
Q

RF for polyps

A 
Age
Overweight
Smoker
FH 
Polyposis syndromes
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22
Q

Colitis Causes

A

IBD
Ischaemic (distal transverse colon where SMA and IMA meet - watershed area)
Infective
NSAIDs

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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
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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

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25
Q

Systemic symptoms of blood loss?

A

Dizziness
Palpitations
Chest pain
SOB

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26
Q

Examination

A 
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
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27
Q

Splanchnic circulation

A

1.8L of flow through circulation per miute
20-40% of total blood volume
portal vein is a major reservoir

28
Q

Class % loss of shock

A 
1 = 10-15%
2 = 15-30%
3 = 3-40%
4 = >40%
29
Q

What is the average circulating volume of blood of a 70kg man?

A

5L

30
Q

Class 1 shock

A

10-15% loss

No clinical signs as physiological compensation

31
Q

Class 2 shock

A

15-30% loss
Postural hypotension
Generalised vasoconstriction

32
Q

Class 3 shock

A

30-40% loss
Hypotension
tachycardia >129
Tachypnoea

33
Q

Class 4 shock

A 
>40% loss
Marked hypotension
tachycardia
tachypnoea
Comatose
34
Q

When restoring blood loss what is important to provide maximum flow?

A

Short wide tube

Poiseuille’s law of flow = 1/length to the power of 4

35
Q

What is the recommendation in restoring blood in a GI bleed?

A

2 wide bore cannulae
large vein
(central line) = 18-14G

36
Q

Cannulae colours and gauge

A 
Red = 14G
Grey = 16G
White = 17G
Green = 18G
Pink = 20G
Blue = 2G
Yellow = 24G
37
Q

Flow rates of different cannulae gauges

A 
Red = 14G = 300ml/min
Grey = 16G = 150ml/min
Green = 18G = 75ml/min
Pink = 20G = 40ml/min
38
Q

benefit of rapid fluid resus

A

Fewer Mis and fewer deaths with rapid blood/fluid resus

39
Q

Transfusion targets

A

Hb>80
If IHD = >100
If chronic liver disease >70

40
Q

massive transfusion risks

A 
fluid overload
electrolyte/acid base disturbance
transfusing products devoid of clotting factors = consider cryoprecipitate/FFP/platelets
hypothermia
iron overload if repeated transfusions
41
Q

Blood tests for GI bleed

A 
ABG
FBC
U&E
LFTs
Coagulation screen
Group & Save compatible bloods for future
42
Q

Platelet target

A

> 50

43
Q

INR target

A

<1.5

44
Q

Initial treatments

A

Anticoagulants hold or reverse anticoagulants to fix INR
PPI decrease lesions in some guidelines before endoscopy?
Tranexamic acid?? -

45
Q

How to reverse warfarin?

A

Vitamin K

Discuss with haematologists = FFP/PPC

46
Q

Variceal bleed specific treatment

A

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
Q

What is MOA of terlepressin?

A

(lysine vasopressin)
mesenteric/splanchnic vasoconstrictor
Decreases portal venous inflow

48
Q

Which AB in variceal bleed?

A

Cephalosporin/quinolone/augmentin

49
Q

Management post resuscitation?

A

Decide whether or not they need endoscopy and how urgent

50
Q

Glasgow glatchford score use

A

To determine risk of patients having a re-bleed before endoscopy and after resus

51
Q

Glasgow glatchford score outcomes

A

Score <2 = low risk upper GI bleed = consider OP endoscopy

>6 = 80% required endoscopic treatment

52
Q

Glasgow glatchford score measurements

A 
Blood urea
Hb
Systolic BP
Pulse
history/co-morbidities
53
Q

Rockall Score Purpose

A

Risk of re-bleed post endoscopy and mortality

Endoscopic diagnosis used to calculate full score

54
Q

What needs to be done/ready if there is an urgent endoscopy to be done?

A
  • good IV access
  • blood available
  • normal BP and Hb>7
  • under GA if agitated = better result and protects airways
55
Q

Ulcers endoscopic management

A

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
Q

Dosage of adrenaline in ulcers endoscopic tx

A

5-40mls

57
Q

varices endoscopic treatment

A

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
Q

Indication for Sengstaken Blakemore tube

A
  • patient already intubated
  • other treatments don’t work in endoscopy
  • under direct supervision with endoscopy
  • experienced staff
59
Q

Post endoscopy/medical therapy for ulcers

A 
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
Q

Mechanism of PPI post endoscopy in clotting

A

PPI increase pH
Low pH activated pepsin which lyses clot and inactivates platelets
So PPI’s prevent this by making less pepsin

61
Q

Success of PPI’s post endoscopy

A

Prevents re-bleeding
Prevents mortality
Reduces need for surgery

62
Q

Why are PPIs not given to everyone?

A 
cost?
electrolyte disturbances
Interactions
Pneumonia
Arrhythmias
C. difficile
Increased mortality in elderly
63
Q

Post endoscopy/medical therapy for varices

A

Beta blockers
Sequential banding procedures
TIPSS procedure = allows blood flow in portal vein to go straight to systemic flow
Liver transplant

64
Q

When is surgery and interventional radiology needed?

A

If endoscopy fails

65
Q

Interventional radiology

A

CT angiogram to find it

Then Angiography to embolise vessels

66
Q

Surgery indications

A
  • uncontrolled further haemorrhage

- failed endoscopic treatment twice

67
Q

Small bowel bleeding

A
  • 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

MET3a (38 decks)

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