GI Bleeding - oesophageal and rectal bleeding Flashcards
What is a Mallory-Weiss tear and how does it present?
Most commonly seen in what kind of patients?
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
How does oesophagitis present and pathophys:
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)
What is the presentation and pathophys of oeophageal varices?
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
What medications can cause GI bleeds?
Aspirin and clopidogrel, Warfarin, Prednisolone, NSAIDs, SSRIs (fluoxetine), Calcium channel blockers.
Immediate management for GI bleeds:
Including the fluid resus
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)
What is the difference between the Blatchford and Rockall scores?
The Rockall score relies on endoscopic results and includes patients characteristics, whereas the Glasgow Blatchford score is based on patient’s clinical
presentation.
List some causes of upper GI bleeds
Mallory-Weiss tear Oesophagitis Gastritis Peptic ulcer Varices Malignancy
Management of variceal upper GI bleed
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),
Non-variceal upper GI bleed management
Adrenaline and mechanical intervention (clips),
Thermal coagulation,
Adrenaline and thrombin (sclerotherapy),
Fibrin.
How would haemorrhoids present?
Risk factors
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
How would ischaemic colitis present?
Risk factors
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
How would Diverticulosis present?
Risk factors
Left LQ pain, guarding, tenderness, Fever, Rectal bleeding, Bloating, constipation
RF: age >50, low dietary fibre intake, leucocytosis, raised inflammatory markers
How would Anal fissures present?
Risk factors
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
Appropriate investigations for chronic rectal bleeding:
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.
What kind of anaemia would be seen with colon cancer?
Hypochromic microcytic anaemia
Difference between presentation of right vs left colon cancers:
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.
Main causes of Duodenal ulcer:
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
Aetiopathology of gastric erosions
Erosion occurs when mucous membrane becomes inflamed
Steroid and aspirin use
Emotional stress, alcohol or secondary to gastritis
Aetiopathology of osephageal varices:
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.
Aetiopathology of gastro-oesophageal cancer
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
Aetiopathology of angiodysplasia:
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.
What does Plummer Vinson syndrome present as?
Dysphagia
Glossitis
Iron deficiency anaemia
A TIPS based procedure connects which two vessels?
Portal and hepatic vein
What is the biggest risk factor for developing hepatic cell carcinoma?
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
What is a Dieulafoy lesion
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.
What are faecal occult blood tests used for in clinical practice?
Identifying individuals to enter screening programme for bowel cancer and get colonoscopy
Why is coffee ground haematemesis less worrying than fresh blood?
Coffee ground - blood has been digested
Fresh - bleeding is NOW
What is hematochezia?
Small bowel or right colon bleeds
Plum coloured bleeds
Till what anatomical structure is it considered UPPER Gi tract?
Ligament of trietz (which is by distal duadenom)
What is Gastric Antral Vascular ectasia? (GAVE)
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
Describe the ABCD in patients with GI bleeds
A - Haematemesis, confusion, dementia can cause reduction
B - SatO2 (normal or low), RR (high)
C - Pulse (normal or high), BP (normal or low)
D -
A loss of how much blood leads to haemodynamic instability?
40% blood loss
What can be given if a patient has to be kept on warfarin despite GI bleed
Vitamin K
Which score can be used to predict mortality after GI bleed?
Rockall score
What does a raised urea level indicate when it comes to a bleed?
Upper GI bleed
Achalasia increases the risk of which cancer?
Squamous cell cancer
