GI bleeding Flashcards
what is the most common GI emergency
GI bleeding
what is the incidence of GI bleeding
incidec of 50-200 per 100,000
where is the highest incidence for GI bleeding
in low socio-economic areas
How much does GI bleeding cost the NHS a year
168 million a year
who is the mortality of GI bleeding increased in
- elderly
- co-morbidity
- anticoagulation drugs
What is the definition of upper GI bleed
- bleeding proximal to the ligament of treitz
What is the definition of lower GI bleeding
- bleeding distal to the ligament of treitz
What do upper GI patients present with
- haematemesis - vomiting - fresh/altered blood
- malaena - black tarry stool
- hematochezia - fresh or altered blood passing rapidly PR - large upper GI bleed
What is malaena
- black tarry stools and has a characteristic smell of altered blood
What is haematochezia and what it is a sign of
- fresh or altered blood passing rapidly PR
- sign of large upper GI bleed
What are the symptoms of lower GI bleed
- malaena
- haematochezia
What is the commonest cause of GI bleeding upper or lower
Upper GI bleeding - accounts for 70%
What is the commonest cause of upper GI bleeding
- Peptic ulcer disease
What are the causes of upper GI bleeding
- Peptic ulcer disease 35-50%
- oesophageal varices 5-10%
- mallory-weiss tear 15%
- oesophagitis
- gastritis/ gastric erosions 8-15%
- Drugs - NSIADS, aspirin, steroids, thrombolytics, anticoagulants
- erosive duodenitis
- portal hypertensive gastropathy
- Upper GI malignancy
- vascular malformation
- can be no cause
What are the causes of lower GI bleeding
- diverticular disease
- haemorrhoids
- mesenteric ischaemia
- coliits
- cancer
- rectal ulcers
- angiodysplasia
- radiation
- drugs
- others
what can cause or are risk factors of peptic ulcer disease
- helicobacter pylori
- NSAIDs
- smoking
- alcohol
what are the symptoms of peptic ulcer disease
- epigastric pain
- nausea
- early satiety - can block the stomach
What are the complications of peptic ulcer disease
- bleeding
- perforation
What are the causes of peptic inflammation
- GORD
- helicobacter pylori
- NSAIDs
- smoking
- alcohol
- obesity
what are varices
- submucosal venous dilation due to increases in portal pressures
What is the causes of portal hypertension leading to gastro-oesophageal varicose
- Pre-hepatic – thrombosis (portal or splenic vein)
- Intra-hepatic – cirrhosis (80% in UK), schistosomiasis (most common worldwide), sarcoid, myeloproliferative diseases, congenital hepatic fibrosis
- Post-hepatic – Budd-Chiari syndrome, right HF, constrictive pericarditis, veno-occlusive disease
what is the most common cause of lower GI bleeding
- diverticular bleed
what is the cause of diverticular bleeding
- straining/constipation
- muscle spasm
- low dietary fibre
- genetics
What are the causes of haemorrhoids
- straining to have a bowel movement
- sitting for long periods of time
- chronic constipation or diarrhoea
- being overweight or obese
- pregnancy
What are the risk factors for polyps
- age over 50 years old
- overweight
- smoker
- polyposis syndrome
- family history of polyps
What can cause colitis
- IBD - either ulcerative colitis or crohns
- ischaemic
- infective
- drug induced
What arteries and where is the ischaemia usually in the bowel
Between superior mesenteric artery and inferior mesenteric artery
How do you manage the patient with an upper GI bleed
- history and examination
- initial assessment and management
- how and when to refer for endoscopy
- therapy at endoscopy
- post OGD management
- discharge and follow up
Why is it important to differentiate between haematemesis and melaena
- helps you to idetify where the bleeding is coming from and what the cause must be
what are the systemic symptoms of blood loss
- dizziness
- palpitations
- chest pain and shortness of breath
In an Upper GI bleed what is in the history
Ask about
- Past GI bleeds
- dyspepsia/known ulcers
- known liver disease or oesophageal varicose
- dysphagia
- vomiting
- weight loss
- check drug and alcohol use
- check comorbidity - CVD, respiratory disease, hepatic or renal impairment, malignancy
Look for signs
- chronic liver disease
- DRE to check for melaena
Is the patient shock
Calculated Rockall score
how do you assess the patient
A - need airway protection or intubation - required in variceal bleeding
B
- need RR and saturations, need oxygen therapy
C
- IV access, IV fluid, blood products
- monitor HR/BP
- more investigations
D
- ACVPU - assess conscious level
E
- abdominal pain
- signs of chronic liver disease
- rectal examination
How do you do fluid resuscitation on a patient
- Poiseuilles law of flow - flow is proportional to the diameter and length
- therefore for maximum flow you want a short and wide tube
- for GI bleed - you want 2 wide bore cannulae in large veins
- 14G to the 18G are widest of the cannulae veins and shortest
describe the different classes of shock and the symptoms of them
Class 1: 10-15% loss (750mls)
- physiological compensation/no clinical signs
Class 2: 15-30% loss (1.5L)
- postural hypotension
- generalised vasoconstriction
Class 3; 30-40% loss (2L)
- hypotension
- tachycardia over 120
- tachypnoea
Class 4: greater than 40% loss (3L)
- marked hypotension, tachycardia and tachypnoea and comatose
Why do you want to correct haemodynamics rapidly
- Rapid correction of haemodynamics results in fewer MI and fewer deaths
Who are the patients that you give transfusions to and what should there haemoglobin aim to be
- in average population target haemoglobin over 80
- in ischaemic heart disease aim for a haemoglobin over 100
- people with chronic liver disease aim for a haemoglobin over 70
What are the complications of massive blood transfusion
- fluid overload
- electrolyte/acid base disturbance
- transfusing products devoid of clotting factors - consider additional FFP/platelets/cryopreciptate
- hypotermia
- patients with repeated blood transfusions may develop iron overload
What blood tests would you want to do
- Blood gas
- FBC
- U and E
- LFT
- coagulation screen
- group and save- find out what blood group and save the serum to enable a cross match at a later time/ cross match - compatible blood
what do PPI do before an endoscopy is given
- decrease lesions at endoscopy and thus decreases need for therapy at endoscopy
- but doesn’t effect transfusion need, surgery need or mortality
what two drugs can be used in GI bleeding
- PPI
- Tranexamic acid
What is the medical management for variceal bleed
Terlipressin
- mesenteric/splanchnic vasoconstrictor
- decreases portal venous inflow
- 34% reduction in mortality for variceal bleed
- give if varices are likely - 1-2mg qds
Prophylactic antibiotics for variceal bleed
- 25% reduction in mortality
- sepsis increases portal pressure
- high risk of aspiration
What is the mechanism of action of terlipressin
- mesenteric/splanchnic vasoconstrictor
What risk stratification score is used for assess a patient before endoscopy to see if they have a high risk of re-bleeding
- Glasgow blatchford score - 1st line - before endoscopy
- rockall score - calculated in patients who have already had an endoscopy
Describe how the Glasgow blatchford score works
- look at specific blood markers
- looks at history
score of under 2
- low risk UGIB - consider outpatient endoscopy
Score of greater than 6
- 80% required endoscopic treatment due to significant GI bleed
How do you treat ulcers
- injection of adrenaline (5-40mls) surrounding the area of ulcers - this causes vasoconstriction and tamponade of the blood vessels
- clip - passed through the endoscope, placed over the ulcer and the clip is closed to prevent any further bleeding
- probe that we pass through the endoscope
- powder delivered through the catheter that promotes clotting in the area it is sprayed onto
How do you treat varices
- endoscopy banding if oesophageal varices
- scleropathy if gastric varices
- Sengstaken blackmore tube if these fail
how does a sengstaken-blakemore tube work
- only used in an intubated patient
- ideally place under direct vision with scope
- placement by experienced staff
- 90% effective
- has a naso balloon and a gastric balloon
- gastric one is inflated FIRST and with traction it is pulled up against the fundus of stomach and this compression stops any flow into the oesophageal varices and stops sensation in bleeding
how do you treat ulcers after endoscopy
PPi
- low pH activates pepsin, this lyses the clott and inactivates platelets
- can prevent re-bleeding, reduces mortality and the need for surgery
- some patients will need continuous infusion for 72 hours to enable lesion healing and optimise coagulation pathway
- helicobacter eradication
- relook OGD to ensure gastric ulcer healing in 6-8 weeks
What are the downsides of PPIs
- side effects - electrolyte disturbances, interactions, pneumonia, arrhythmias, C.difficile
- increase mortality in elderly
- cost
What is the prophylactic treatment for varies
1st line
- non selective beta blockers = Propranolol (e.g. 20-40mg/12h PO)
2nd line
- TIPSS for resistant varices - use rebanding and non-selective Beta blockade
when is interventional radiology and surgery needed in GI bleeding
- this is if the endoscopy fails twice or the person is too unwell to have an endoscopy
- re-bleed despite endoscopic treatment
- refer to surgery if interventional radiology is not available
What is the interventional radiology used in GI bleeding
- CT angiogram
- angiography to embolise vessel
What is surgery reserved for in GI bleeding
- uncontrolled further haemorrhage
- failed endoscopic treatment x2
What is the most common cause of small bowel bleeding
- Angiodysplasia
How do you diagnose the lesion in small bowel bleeding
- video capsule endoscopy
Others
- CT angiography
- red cell scan
How do you treat lesions in small bowel bleeding
Balloon enteroscopy
other treatments
- interventional angiography
What is a mallory-weiss tear
- this is a tear is oesophageal mucosa following retching or vomiting or due to an increased intra-oesophageal pressure (seizures, hiccups, straining) or occurring spontaneously (alcohol use, advanced age, presence of hiatal hernias)
What are the signs of shock
- peripherally cool - capillary refill time >2s, urine output <0.5mL/Kg/H
- reduced GCS or encephalopathy
- tachycardia
- SBP <100mmHg, postural drop >20mmHg
Describe the Rockall Risk score for upper GI bleeds
Pre- endoscopy
- age
- shock (SBP and HR)
- Comorbidity
Post endoscopy
- Diagnosis
- Sings of recent haemorrhage and at endoscopy
Pre endoscopy 0 points - age = under 60 years old - shock (SBP and HR) = >100mmHg, <100bpm - Comorbidity = Nil Major
1 points
- Age = 60-79 years
- SBP >100mmhg
- HR > 100bpm
- Co morbidity = heart failure and IHD
2 points
- Age = >80 years
- SBP = < 100mmHg
- Co morbidity = renal or liver failure
3 points
- co morbidity = metastases
Post endoscopy
0 points
- mallory-weiss tear
- no signs or a dark red spot at endoscopy
1 point
- all other diagnoses
2 points
- upper GI Malignancy
- blood in upper GI tract, adherent clot, visible vessel
What is the rockall risk score
- risk score that is calculated based on pre endoscopy criteria which is then added to post endoscopy criteria for the final score which predicts risk of rebleeding and death to upper GI bleeds
What is the acute management of a patient with an upper GI bleed that is shocked
- Protect airway and keep NBM
Insert two large-bore (14-16G) IV cannulae - Urgent bloods: FBC, LFT, glucose, clotting screen, crossmatch 4-6 units
- Rapid IV crystalloid infusion up to 1L
- If signs of grade III or IV shock give blood
Group specific or O Rh-ve until crossmatch done - Otherwise continue IV fluids to maintain BP and transfuse if eg Hb<70g/L
- Correct clotting abnormalities (vitamin K, FFP, platelet concentrate)
- If risk of varices (eg known liver disease or alcohol excess), give Terlipressin IV 1-2mg/6h and broad-spectrum IV Abx
- Consider referral to ICU and consider CVP line to guide fluid replacement
- Aim for >5cmH2O CVP may mislead if there is ascites or CCF - Catheterise and monitor urine output
- Aim for >30mL/h - Monitor vital signs every 15mins until stable, then hourly
- Notify surgeons of all severe bleeds
- Urgent endoscopy for diagnosis ± control of bleeding at the earliest possible point after adequate resuscitation
how do you treat a patient with an upper GI bleed that is haemodynamically stable
- Insert two large-bore (14-16G) IV cannulae and take blood for FBC, U&E, LFT, clotting, and group&save
- Rapid IV crystalloid infusion up to 1L to restore intravascular volume
- Avoid saline if cirrhotic/varices
- Consider a CVP line to monitor and guide fluid replacement - Organise CXR, ECG and check ABG
- Consider a urinary catheter and monitor hourly urine output
- Transfuse if significant Hb drop (<70g/L)
- Correct clotting abnormalities (vitamin K, FFP, platelet concentrate)
- If risk of varices (eg known liver disease or alcohol excess), give Terlipressin IV 1-2mg/6h for ≤3d and broad-spectrum IV Abx (eg Piperacillin/Tazobactam IV 4.5g/8h)
- Monitor HR, BP and CVP (keep >5cmH2O) at least hourly until stable
- Arrange an urgent endoscopy
- If endoscopy fails, surgery or emergency mesenteric angiography/embolisation may be needed
- For uncontrolled oesophageal variceal bleeding, a Sengstaken-Blakemore tube may compress the varices, but should only be placed by someone with experience
what’s your percentage change of death from a rebleed
40% of patients who rebleed will die
What should you do if there is a rebleed
- check vital signs every 15 minutes and call senior cover for repeat endoscopy and/or surgical intervention
What are the signs of a rebleed
- rising HR
- falling JVP and decreasing hourly urine output
- haematemesis or fresh melaena (normal to pass decreasing amounts of melaena for 24 hours post haemostats as blood makes its way through the GI tract)
- fall in BP (late and sinister finding) and decreased consciousness level
What is the further management after an upper GI bleed
- Re-examine after 4h and consider the need for FFP if >4 units transfused
- Hourly HR, BP, CVP, urine output (4hrly if haemodynamically stable may be ok)
- Transfuse to keep Hb>70g/L; ensure a current valid group & save sample
- Check FBC, U&E, LFT and clotting daily
- Keep NBM if at high rebleed risk
What is a high risk peptic ulcer bleed
- active bleeding
- adherent clot
- non bleeding visible vessel
What is the management of a high risk peptic ulcer bleed
- Endoscopic haemostasis
- Admit
- Start PPI
- If haemodynamically stable start oral foods and clear water 6 hours after endoscopy
- If positive for H.pylori treat
what is a low risk peptic ulcer bleed
- flat
- pigmented spot or clean base
What is the treatment for a low risk peptic ulcer bleed
- Give oral PPI
- Patient can eat 6 hours after endoscopy
- If positive for H. pylori treat
What are the risk factors for a vatical bleed
- increase in portal pressure
- variceal size
- endoscopic features of the variceal wall
- advanced liver disease
How does a lower GI bleed present
- passage of dark blood and clots without shock or fresh blood (as opposed to melaena in upper GI bleed)
massive bleeding from the lower GI tract is …
rare
- bleeding in the lower GI tract is usually due to diverticular disease or ischaemic colitis
How is a diagnosis of a lower GI bleed made
- based on history and examination
- DRE
- then imaging
What imaging can be used in a lower GI bleed
- Proctoscopy - e.g. anorectal disease, haemorrhoids
- Flexible sigmoidoscopy or colonoscopy - IBD, cancer, ischaemic colitis, diverticular disease, angiodysplasia
- video capsule endoscopy
- Angiography - to seek vascular abnormality; yield is low so last resort
How would you investigate isolated episodes of PR bleeding in the young
<45 years
- only require DRE and flexible sigmoidoscopy because the probability of a significant proximal lesion is very low, unless there is a strong family history of colorectal cancer at a young age
What is the management of the lower GI bleed
- most acute lower GI bleeds start and stop spontaneously
- few patients who continue bleeding and are haem-dynamically unstable and will need resuscitation as per upper GI bleeding
- surgery rarely required
How does a chronic GI bleed present
- patients typically present with iron deficiency anaemia
chronic blood loss producing iron deficiency in all men and all women after menopause is always due to…
bleeding from the GI tract
- primary concern is to exclude cancer and coeliac disease
What are the causes of chronic blood loss
- cancer
- coeliac disease
- hookworm - most common cause worldwide of chronic GI bleeding
How do you diagnose a chronic GI bleed
- site of bleeding usually indicated by history and examination
use both upper and lower GI endoscopically
describe the imaging that should be used in a chronic GI bleed
- Upper GI endoscopy – usually performed first; duodenal biopsies should be taken to diagnosis coeliac disease even if coeliac serology has been performed
- Colonoscopy – follows; any lesion should be biopsied or removed, though it is unsafe to presume that colonic polyps are the cause of chronic blood loss
- Unprepared CT – reasonable test to look for colon cancer in frail patients
- CT colonography – can be used as alternative to colonoscopy
What is the management of a chronic GI bleed
- treat cause
- iron supplements for anaemia (oral, sometimes infusions required)
What are the complications of a massive blood transfusion
- coagulopathy
- volume overload
- hypothermia
- Hyperkalemia may be caused by lysis of stored red cells and is increased in irradiated red blood cell
- Metabolic alkalosis and hypokalemia may be caused by the transfusion of a large amount of citrated cells.
How do you know the difference between right and left sided bleeds in lower GI bleeds
- Right sided bleeds tend to be darker coloured blood that left sided bleeds
How do you treat a lower GI bleed
- Prompt correct of haemodynamic compromise is required
- When haemorrhoidal bleeding is suspected a proctosigmoidscopy is reasonable
- Angiogram can show a bleeding point and is used with a proctosigmoidoscopy is not reasonable
- Patients who are more stable the standard procedure is colonoscopy
- In patients with UC who have significant haemorrhage the standard approach is a sub total colectomy
what are the indications for surgery in a GI bleed
- Patient over 60 years
- Continued bleeding despite endoscopic intervention
- Recurrent bleeding
- Known CV disease with poor response to hypotension
