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Junior Surgery- GI > GI bleeding > Flashcards

GI bleeding Flashcards

1
Q

What is haematemesis?

A

Vomiting blood

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2
Q

What is malaena?

A

Black stools

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3
Q

What are causes of maleana?

A

GI haemorrhage/bleed

  • Peptic ulcer disease
  • Oesophageal varices
  • Oesophagitis
  • Gastritis
  • Mallory–Weiss tear
  • Neoplasm
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4
Q

What is the mechanism behind malaena?

A

Bleeding from any cause in the upper gastrointestinal tract can result in melaena. It is often said that bleeding must begin above the ligament of Treitz; however, this is not always the case.

The black, foul-smelling nature of the stool is due to the oxidation of iron from the haemoglobin, as it passes through the gastrointestinal tract.

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5
Q

What are common causes of upper GI bleeding?

A
  • Peptic ulcers
  • Mallory-Weiss tears
  • Oesophageal varcies
  • Gastritis/Gastric ulcers
  • Drugs
  • Oesophagitis
  • Duodenitis
  • Malignancy
  • No Obvious cause
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6
Q

What drugs can cause upper GI bleeding?

A
  • NSAIDs
  • Aspirin
  • Steroids
  • Thrombolytics
  • Anticoagulants
  • Alcohol
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7
Q

What would you want to ask someone who was presenting with features of an upper GI bleed?

A
  • Past GI bleeds
  • Dyspespsia/known ulcers
  • Known liver disease/oesophageal varices
  • Dysphagia
  • Vomiting
  • Weight loss
  • Drugs and alcohol use
  • Serious comorbidities - CVS, Resp, hepatic/renal, malignancy
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8
Q

What symptoms can occur in an acute upper GI bleed?

A
  • Haematemesis
  • Malaenia
  • Dizziness/Psotural Syncope
  • Abdo pain
  • Dysphagia
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9
Q

What signs might indicate someone is having an upper GI bleed?

A
  1. Signs of liver disease - telangiectasia, purpura, jaundice
  2. Signs of shock
  • Hypotension (SBP <100mmHg)/Postural drop >20 mmHg
  • Tacycardia
  • Decreased JVP
  • Decreased Urine output
  • CRT>2s
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10
Q

What bloods would you perform if someone presented with upper GI bleed, and why would you perform each?

A
  • FBC - blood loss
  • U+E’s - increased urea
  • Clotting - coagulopathy of liver disease
  • Glucose
  • LFTs - varices risk
  • Crossmatch/G+S - large bleed
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11
Q

Why would you consider putting in a CVP monitor in someone recieving blood transfusion for an acute GI bleed?

A

To assess transfusion adequacy and overload on the heart

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12
Q

When would you consider transfusion in someone with an upper GI bleed?

A
  • Haemoglobin <80 g/L
  • Patients with active bleeding
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13
Q

What drugs would you want to check for (and stop) in someone having an acute GI bleed?

A
  • NSAID’s
  • Aspirin
  • Clopidogrel
  • Warfarin
  • Consider stopping drugs masking shock features - B-blockers, antiarrythmia, anti-hypertensives
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14
Q

What can cause Mallory-Weiss tears?

A

Sudden inicrease in intra-abdominal pressure

  • Heavy coughing
  • Heavy wretching/dry heaves
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15
Q

How would you manage a varcieal upper GI bleed?

A
  • IV Terlipressin - give before endotherapy
  • Prophylactic Broad-spectrum IV antibiotics
  • Endotherapy - variceal ligation/Sclerotherapy
  • Consider balloon tamponade
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16
Q

What can be used to control uncontrolled variceal bleeding?

A
  • Trans-jugular intrahepatic porto-systemic shunt (TIPS)
  • Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
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17
Q

How would you manage bleeding ulcers?

A
  • Haemostatic therapy - 2 out of 3/3 out of 3 of clips, cautery or adrenaline
  • Post endoscopic PPI’s
  • Consider H. Pylori erdication therapy
  • Discontinue causative therapies - NSAIDs, aspirin
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18
Q

What scoring systems are used to stratify Upper GI bleeds?

A
  • Glasgow-Blatchford bleeding score - initial risk assessment of acute upper GI bleed
  • Rockall score - identify patients at risk of complications following acute upper GI bleed
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19
Q

What is coffee-ground vomit suggestive of?

A

Slow, intermittent bleed

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20
Q

What is regarded as the point which distinguishes an upper GI bleed from a lower GI bleed?

A

Ligament of trietz

21
Q

Which does coffee-ground vomit indicate as a cause of haematemesis; peptic ulcers or variceal bleeding?

A

Peptic ulcers

22
Q

What would brisk haematemesis be indicative of as a cause?

A
  • Variceal bleeding
  • Actively bleeding gastro-duodenal ulcer
23
Q

What is haematochezia most commonly associated with; UGIB or LGIB?

A

LGIB - but can be upper in severe UGIB

24
Q

Why might urea be raised in an upper GI bleed?

A

As blood passes through the small bowel and is partially digested, it can result in an elevated urea and urea/Cr ratio - equivalent to a large protein meal

25
Q

What proportion of oesophageal varices will rebleed in a year?

26
Q

What are the major causes of lower GI tract bleeding?

A
  • Diverticular disease
  • Ischaemic colitis
  • Neoplasia
  • Haemorrhoids
  • Angiodysplasia
27
Q

What are causes of lower GI bleeding?

A
  • Diverticulitis
  • Colonic carcinoma
  • Meckel’s Diverticulum
  • Ischaemic colitis
  • Polyps
  • Crohn’s/Colitis
  • Haemorrhoids
  • Anal fissure
  • Angiodysplasia
28
Q

What is angiodysplasia?

A

Small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia.

It resembles telangiectasia and development is related to age and strain on the bowel wall. It is a degenerative lesion, acquired, probably resulting from chronic and intermittent contraction of the colon that is obstructing the venous drainage of the mucosa

29
Q

What is haematochezia?

A

Bright red blood in the stool

30
Q

What is haematochezia indicative of in terms of location of a GI bleed?

A

Lower GI bleed

31
Q

What investigations would you consider doing in someone presenting with features of a lower GI bleed?

A
  • Examination + PR
  • Bloods - FBC, U+E’s, LFT’s, Coagulation, Crossmatch/group and save
  • Consider colonoscopu/sigmoidoscopy/Proctoscopy
  • Consider CT angiography
  • Consider Capsule endoscopy
32
Q

If you were performing protoscopy on someone with features of LGIB, what might you be looking for?

A
  • Haemorrhoids
  • Anorectal disease
33
Q

What would you be looking for on sigmoidoscopy/colonoscopy in someone with LGIB?

A
  • Inflammatory bowel disease
  • Cancer
  • Ischaemic colitis
  • Diverticular disease
  • Angiodysplasia
34
Q

How does chronic GI bleeding tend to present?

A

Iron Deficiency anaemia

35
Q

What investigations would you consider doing in the context of chronic GI bleeding?

A
  • Upper GI endoscopy
  • Colonoscopy
  • CT colonography/Unprepaired CT
36
Q

What mnemonic can be used to remember causes of Haematemesis?

A

GUM BLEEDING

  • Gastritis
  • Ulcer (peptic)
  • Mallory-Weiss (tear of the lower oesophageal mucosa)
  • Biliary (haemobilia – post cholecystectomy/liver biopsy)
  • Large varices
  • Esophagitis (Oesophagitis)
  • Entero-aortic fistula (after repair of aortic aneurysm)
  • Duodenitis (peptic ulcer)
  • Inflammatory bowel disease (rare)
  • Neovascularisation (rare)
  • Gastric carcinoma (unusual)
37
Q

What assessment/investigations would you consider doing in someone with features of a GI bleed?

A
  • Examination
  • Bedside - NEWS, urine output
  • Bloods - FBC, U+Es, LFTs, Clotting, glucose, G&S/crossmatch
  • CXR/AXR
  • OGD
38
Q

How would you immediately manage an acute GI bleed?

A

ABCDE

  • 2 wide bore cannulas
  • IV fluid resus - consider major haemorrhage activation

Following ABCDE

  • Keep NBM
  • Correct clotting abnormalities
  • Stop antiplatelet/anticoagulant
  • Specific Manage based on cause - Variceal vs non-variceal
  • Treat any concurrent issues e.g. encephalopathy, alcohol withdrawal
39
Q

When would you consider givig a platelet transfusion in someone with an upper GI bleed?

A

Platelets < 50x109

40
Q

How does terlepressin work in a GI bleed?

A

Spanchnic vasoconstrictor that reduces portal blood flow

41
Q

What would you give someone on warfarin who was having an upper GI bleed?

A

Vitamin K + prothrombin complex

42
Q

What wuld you give someone who was on a DOAC who was having an upper GI bleed?

A
  • Praxibind - dabigatran
  • Prothrombin complex - others
43
Q

How would you manage someone who was coagulopathic for reasons other than low platelets, warfarin or doac therapy?

A

Vit K +/- FFP

44
Q

What would you treat a low fibrinogen with in someone with a GI bleed?

A

Cryoprecipitate

45
Q

How would specifically manage a non-varcieal bleed?

A
  • Endoscopic intervention
    • Adrenaline injection to peptic ulcer
  • Pharmacological
    • IV PPI after endoscopy
    • Consider other therapy e.g. tranexamic acid
46
Q

What is the glasgow-blatchford score?

A

Score system which can assess likelihood patient will need intervention during endoscopy (pre-endoscopy test)

47
Q

What is the rockall score?

A

Mortality risk assessment post-endoscopy

48
Q

How would you manage variceal bleeding post-intervention to prevent further bleeding?

A
  • Propranalol
  • Variceal banding
  • TIPSS
  • Liver transplant
49
Q

Why is TIPSS used to prevent further variceal bleeding?

A

Allows blood to flow out of the portal system into a hepatic vein

Junior Surgery- GI (43 decks)

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