GI bleeds Flashcards
How can GI bleeds be classified?
-
upper GI bleeding (proximal to D-J flexure)
- variceal bleeding
- non-variceal bleeding
- lower GI bleeding (distal to DJ flexure)
Upper GI bleeding is 4x more comon than lower GI bleeding, emergency resuscitation is the same for both though
ABATED
How would you manage an acute GI bleed in an emergency setting?
- ABCDE
- Bloods → FBC / U+Es / LFTs / INR / G+S / Cross match 2u
- IV Access
- Transfuse
- Endoscopy
- Drugs → stop anticoagulation
Always remember to reassess ABCDE, the Rockall score is used for risk categorisation for upper GI rebleeding + mortality.
Once pt stable, take history, review, document, discuss + handover.
How would you estimate the degree of blood loss with vital signs?
- RR, HR, BP can be used to estimate degree of blood loss/hypovolaemia
What is the 3-fold aim of history and examination for GI bleeding?
- identify likely source - upper vs lower + potential cause
- determine severity of bleeding
- identify precipitants (eg. drugs)
What is important to ask in the presenting complain and history of presentic complaint of a GI bleed history?
- duration, frequency, volume (indicate severity)
- nature of bleeding
- haemetemesis or melaena
- PR dark red blood -> colon
- PR bright red blood -> rectum, anus
- if PR bleeding, is blood being alone or with bowel opening
- if with bowel opening, is blood mixed w/ stool (colonic), coating stool (colonic/rectal), in toilet water (anal) or wiping (anal)
- ask about associated upper/lower GI symptoms
- abdo pain, dyspepsia
- lower abdo pain, bowel symptoms (dirrhoea)
- changes in bowel habit
- anorexia, weight loss, n+v, bloating, jaundice
- previous episodes of bleeding and cause
- nocturnal? - try and SOCRATES the bleed
http://bestpractice.bmj.com/topics/en-gb/456/diagnosis-approach
What is important to ask in the past medical history for GI bleeds?
- history of GI disease - IBD, IBS, malignancy, GORD, PUD, liver disease etc.
- bleeding disorders - haemophillia
- other medical conditions
- surgical history - appendectomy, colectomy, c-section
- any recent hospital admissions?
What is important in the medication history for GI bleeds?
- anti-platelets or anti-coagulants
- GI meds - laxatives, loperamide, PPIs, H2 antags, antacids
- regular medications - NSAIDs, steroids, bisphosphonates
- contraception - ectopic, pregnancy, miscarriage
- over the counter drugs
- allergies or intolerances?
What is important in the social history for GI bleeds?
- alcoholics at risk of liver disease + poss variceal bleeds
- smokers at risk of PUD
- travel history / sexual history / physical contact
- tattoos / piercings / rec drug / iv drug
- diet (lack of fibre, gluten, fatty foods)
- living situation
- activities of daily living
- occupation
want to rule out infections such as H. Pylori or any hepatitis
Upper GI bleeding refers to bleeding from oesophagus, stomach, duodenum (ie proximal to ligament of treitz). What are the differentials for an upper GI bleed?
- severe oesophagitis
- mallory-weiss tear
- oesophageal varices
- oesophageal cancer
- gastric ulcer
- gastric erosions
- gastric varices
- gastric cancer
- duodenal ulcer
- duodenitis
nb. bleeding from jejunum/ileum is not common
What is haematemesis?
- vomiting of blood
- can be bright red from fresh bleeding site
- or coffee-ground appearance if from stomach over longer time
What specific questions would you want to ask a patient with haematemesis?
- appearance of vomit: eg. coffee-ground - peptic ulcer
- elicit symptoms to see if pt haemodynamically stable
- retching or nausea - mallory-weiss tear
- quantity: large amounts + bright red - oesophageal varices
- pain - peptic ulcer / gastritis / duodenitis
- alcoholics - varcies / ulcers
- B-symptoms: anorexia, dysphagia, weight loss - malignancy
- medications - NSAIDs, warfarin, steroids
What is melaena?
- faecal output from anus following a bleed from upper GI tract
- stools look black and tarry
- melaena can occur bc of bleeding anywhere from oesophagus to right sided colon
- generally bleeding has to be slow enough to allow time for blood to be chemically altered during transit through bowel
What are important questions to ask a patient with melaena?
- is the patient haemodynamically stable?
- colour of blood - the lighter it is, the more distal
- if blood is mixed w/ motion or coated or on surface
- any pain on defacation
- diarrhoea and constipation
- abdominal pain - socrates
- anaemia symptoms
What would examination of a patient with a GI bleed reveal?
- reduced level of consciousness
- pale and clammy
- cool peripheries
- reduced CRT
- tachycardic + thready pulse
- hypotensive with narrow pulse pressure
- tenderness on abdo exam can point to underlying cause
- stigmata of chronic liver disease (palmar erythema, leukonychia, dupuytrens, shifting dullness/ascites)
- digitial rectal exam -> melaena, dark red/bright red blood?
- signs of anaemia
What is meant by occult GI bleeding?
Occult gastrointestinal bleeding is defined as gastrointestinal bleeding that is not visible to the patient or physician, resulting in either a positive fecal occult blood test, or iron deficiency anemia with or without a positive fecal occult blood test