GI Bleeding - oesophageal and rectal bleeding

Question 1

What is a Mallory-Weiss tear and how does it present?

Most commonly seen in what kind of patients?

Answer 1

Haematemesis, abdo pain, involuntary ratching, melaena

Normally have a chronic history of alcoholism or bulimia. Increased pressure at the oesophago-gastric junction from constant retching and vomiting can cause laceration in mucosa. Other causes are chronic cough, hiatus hernia, retching during an endoscopy

Can spontaneously stop. Tear is at level of cardiac sphincter

Question 2

How does oesophagitis present and pathophys:

Answer 2

Dysphagia, impaction of food, chest discomfort (heartburn), N&V, abdo pain

Highly associated with hiatus hernias. Sliding hernias (80%), rolling hernias (20%), eosinophillic oesophagitis (allergic response)

Question 3

What is the presentation and pathophys of oeophageal varices?

Answer 3

 Haematemesis,
 Melena,
 Haematochezia (anal bleeding),
 Jaundice.

Dilation of the veins of the lower oesophagus is due to congestion of blood from increased portal
hypertension. This can be caused by liver cirrhosis, liver disease, alcoholism and hepatitis infection.
As a consequence of portal HTN, encephalopathy, splenomegaly and peripheral oedema are common

Question 4

What medications can cause GI bleeds?

Answer 4

 Aspirin and clopidogrel,
 Warfarin,
 Prednisolone,
 NSAIDs,
 SSRIs (fluoxetine),
 Calcium channel blockers.

Question 5

Immediate management for GI bleeds:

Including the fluid resus

Answer 5

ABCDE pathway
Blood transfusions or IV fluids given with a cannula (large-bore). Also take blood for tests -> Higher urea than creatinine makes the bleed more significant. Group and save, blood gas, FBC, cross match, WCC, LFTs
Crystalloid saline fluid in 15 mins
Discontinuation of anti-coagulants
Risk assessment of the severity of bleed using the Blatchford or Rockall scores
Endoscopy after resus (can give PPIs beforehand to stop bleeding if not suspecting variceal bleed)

Question 6

What is the difference between the Blatchford and Rockall scores?

Answer 6

The Rockall score relies on endoscopic results and includes patients characteristics, whereas the Glasgow Blatchford score is based on patient’s clinical
presentation.

Question 7

List some causes of upper GI bleeds

Answer 7

Mallory-Weiss tear
Oesophagitis
Gastritis
Peptic ulcer
Varices 
Malignancy

Question 8

Management of variceal upper GI bleed

Answer 8

Telipressin (vasopressin)/ Octreotide (somatostatin analogue) for 5 days once haemostasis has reached
Band ligation or sclerotherapy
Endoscopic injection of N-butyl-2-cyanoacrylate,
Prophylactic antibiotic therapy - quinolones
TIPS (trans-jugular intrahepatic portosystemic shunts),

Question 9

Non-variceal upper GI bleed management

Answer 9

Adrenaline and mechanical intervention (clips),
 Thermal coagulation,
 Adrenaline and thrombin (sclerotherapy),
 Fibrin.

Question 10

How would haemorrhoids present?

Risk factors

Answer 10

Rectal bleeding (bright red blood in stools), pruritis ani (itchy bottom), perianal pain 
Examination: Tender palpable perianal lesion 
Internal haemorrhoids usually painless with bloody stools, external haemorrhoids often result in pain and swelling 

RF: age 45-65, history of constipation, anal intercourse, pregnancy

Question 11

How would ischaemic colitis present?

Risk factors

Answer 11

Abdominal pain, haematochezia, melena, diarrhoea, abdominal bruit

RF: old age, smoker, AF, MI, vasculitis

Superior and mesenteric arteries supplying the colon are occluded due to thromboembolism.
Most affected areas are part of colon wit least collateral vasculature (e.g. the splenic flexure - a watershed site)
X-ray showing a thumb-printing sign at splenic flexure

Question 12

How would Diverticulosis present?

Risk factors

Answer 12

Left LQ pain, guarding, tenderness, Fever, Rectal bleeding, Bloating, constipation

RF: age >50, low dietary fibre intake, leucocytosis, raised inflammatory markers

Question 13

How would Anal fissures present?

Risk factors

Answer 13

Pain of defaecation, haematochezia, anal spasm

Usually a complication of crohn’s
Diagnosis made with perianal inspection
PR exam may not be possible due to pain and muscle spasms

Question 14

Appropriate investigations for chronic rectal bleeding:

Answer 14

Faecal occult blood test -> FBC to test for iron deficient anaemia -> colonoscopy -> upper endoscopy
-> capsule endoscopy -> CT enterography.

FBC (INR, anaemia, group and save for antibody group for blood transfusion, inflammatory
markers),

 Stool sample for helicobacter pylori (increases risk of duodenal ulcers and gastric cancer),
 ABGs and ECGs,
 Flexible sigmoidoscopy or colonoscopy.

Question 15

What kind of anaemia would be seen with colon cancer?

Answer 15

Hypochromic microcytic anaemia

Question 16

Difference between presentation of right vs left colon cancers:

Answer 16

Right colon cancers: weight loss, anaemia, occult bleeding, mass in right iliac fossa, disease
more likely to be advanced at presentation.

Left colon cancers: often colicky pain, rectal bleeding, bowel obstruction, tenesmus, mass in left iliac fossa, early change in bowel habit, less advanced disease at presentation.

Question 17

Main causes of Duodenal ulcer:

Answer 17

H. pylori infections (gr -) - 95% of cases
Inflammation caused causes erosion of protective mucosa and further damage by stomach acid forming an ulcer

NSAIDS (only 2% of cases)

Zollinger-Ellison syndrome
Small tumours form in pancreas and upper duodenum

Smoking, stress and alcohol are risk factors

Question 18

Aetiopathology of gastric erosions

Answer 18

Erosion occurs when mucous membrane becomes inflamed

Steroid and aspirin use
Emotional stress, alcohol or secondary to gastritis

Question 19

Aetiopathology of osephageal varices:

Answer 19

Extremely inflamed sub-mucosal veins in LOWER third of oesophagus

Portal hypertension due to liver cirrhosis in often the cause as lower oesophageal veins to act as collateral circulation.

Question 20

Aetiopathology of gastro-oesophageal cancer

Answer 20

Squamous cell carcinoma (common in developing world) or oesophageal adenocarcinoma (developed world)

Adenocarcinoma - arise in glandular cells in lower third of oesophagus. Often with Barrett’s oesophagus (squamous cells undergo metaplasia into simple columnar). RF = smoking tobacco, obesity and GORD

Squamous cell carcinoma - occurs in upper 2/3 of of oesophagus
RF = tobacco, alcohol, hot drinks, poor diet

Question 21

Aetiopathology of angiodysplasia:

Answer 21

Small vascular malformation of the gut, usually in caecum or ascending colon
Age related and increased strain on bowel
Obstructs venous drainage on mucosa, capillaries gradually dilate, precapillary sphincter becomes incompetent.
Risk is increased by coagulation disorders and when anticoagulants are prescribed.

Question 22

What does Plummer Vinson syndrome present as?

Answer 22

Dysphagia
Glossitis
Iron deficiency anaemia

Question 23

A TIPS based procedure connects which two vessels?

Answer 23

Portal and hepatic vein

Question 24

What is the biggest risk factor for developing hepatic cell carcinoma?

Answer 24

The main risk factor for developing HCC is liver cirrhosis, for example secondary* to hepatitis B and C, alcohol, haemochromatosis and primary biliary cirrhosis.

Other risk factors include:
alpha-1 antitrypsin deficiency
hereditary tyrosinosis glycogen storage disease
aflatoxin drugs: oral contraceptive pill, anabolic steroids
porphyria cutanea tarda, male sex, diabetes mellitus, metabolic syndrome

Question 25

What is a Dieulafoy lesion

Answer 25

Tortuous arteriole, typically located in the upper stomach, which can cause an upper gastrointestinal bleed.
CONGENITAL
Upper gastrointestinal bleed can present with both haematemesis and melaena.

Question 26

What are faecal occult blood tests used for in clinical practice?

Answer 26

Identifying individuals to enter screening programme for bowel cancer and get colonoscopy

Question 27

Why is coffee ground haematemesis less worrying than fresh blood?

Answer 27

Coffee ground - blood has been digested

Fresh - bleeding is NOW

Question 28

What is hematochezia?

Answer 28

Small bowel or right colon bleeds

Plum coloured bleeds

Question 29

Till what anatomical structure is it considered UPPER Gi tract?

Answer 29

Ligament of trietz (which is by distal duadenom)

Question 30

What is Gastric Antral Vascular ectasia? (GAVE)

Answer 30

Watermelon Stomach”, is a condition in which the blood vessels in the lining of the stomach become fragile and become prone to rupture and bleeding. The stomach lining exhibits the characteristic stripes of a watermelon when viewed by endoscopy

Question 31

Describe the ABCD in patients with GI bleeds

Answer 31

A - Haematemesis, confusion, dementia can cause reduction
B - SatO2 (normal or low), RR (high)
C - Pulse (normal or high), BP (normal or low)
D -

Question 32

A loss of how much blood leads to haemodynamic instability?

Answer 32

40% blood loss

Question 33

What can be given if a patient has to be kept on warfarin despite GI bleed

Answer 33

Vitamin K

Question 34

Which score can be used to predict mortality after GI bleed?

Answer 34

Rockall score

Question 35

What does a raised urea level indicate when it comes to a bleed?

Answer 35

Upper GI bleed

Question 36

Achalasia increases the risk of which cancer?

Answer 36

Squamous cell cancer