GI Bleeds Flashcards
What are the clinical features of an acute upper GI bleed?
- Signs of chronic liver disease (jaundice, abdominal distension)
- Melaena
- Cool peripheries
- Cap refill > 2 seconds
- Tachycardia
- Hypotension (systolic BP < 100)
- Haematemesis (looks like coffee)
- Abdominal pain
Where can bleeding occur from in cases of upper GI bleeds and what anatomical landmark is used to differentiate between upper and lower GI bleeds?
- Oesophagus
- Gastric
- Duodenum
=> Ligament of Treitz - also known as the suspensory ligament of the duodenum
What are the possible differential diagnoses of upper GI bleeds?
- Peptic ulcers
- Oesophageal or gastric varicies
- Oesophagitis
- Upper GI tumours
What are the risk factors of Upper GI bleeding?
- Regular aspirin use
- History of peptic ulcers
- Old age
- GORD
What are the causes of upper GI bleeds?
=> Cause depends on where the bleed is occuring from
=> Oesophaegeal Bleeding:
- Oesophagitis
- Oesophageal varicies
- Cancer
- Mallory Weis Tear
=> Gastric Bleeding:
- Gastric ulcer
- Gastric cancer
- Dieulafoy lesion
- Diffuse erosive gastritis
=> Duodenal causes:
- Posterior duodenal ulcer
What are the investigations for suspected upper GI bleeding?
=> PR exam
- Evidence of Malena
=> Endoscopy and Biopsy
- Identify region of bleeding and exclude cancer as differential
=> Colour of vomit and stools
- Fresh red vomit?
- Black vomit?
- Vomit streaked with blood?
- Black or bloody stools?
=> Assessment of severity
- Blatchford score used to determine need for endoscopy
- Rockall risk scoring system
What is meant by occult GI Bleeding?
Bleeding that is not visible to the patient or doctor
What is the management of acute upper GI bleeding?
=> Focussed on treating the cause
- Admit to hospital, crossmatch blood and check FBC, LFTs, U+E and Clotting
- If patient in shock, protect airway and rapid IV crystalloid infusion. Require O- blood
- If risk of varicies, give Terlipressin
- If stable, send for Upper GI Endoscopy within 24 hours. Need for Endoscopy is calculated throw the Blatchford Score
- Patients with oesophagitis or gastritis, give proton pump inhibitor
- Mallory Weiss Tear tends to recover without intervention
- IV Adrenaline and Omeprazole once bleeding site is identified to lower risk of re-bleeding
- Rockall score calculated to determine risk of re-bleeding
What are the indications for surgery in cases of upper and lower GI Bleeds?
- Age > 60
- Continued bleeding despite endoscopic intervention
- Recurrent bleeding
- Known cardiovascular disease with poor response to hypotension
What is the primary prevention for people with peptic ulcers?
- Stop smoking
- Decrease alcohol intake
- Decrease aspirin doses
- Take all medications with food
What is the secondary prevention for people with peptic ulcers?
Self examination of cough, vomit and stools
What are the clinical features of lower GI Bleeds?
- Red or dark red stools
- Haematochezia (some upper GI blleds can also present as this)
=> Right sided bleeds tend to be darker than left sided bleeds
What are the causes of lower GI Bleeds?
- Colitis - presentation of diarrhoea is common
- Diverticular disease - small amount of dark blood
- Cancer
- Haemorrhoidal bleeding - bleeding rarely sufficient to cause haemodynamic compromise
- Angiodysplasia (small vascular malformation in the gut)
What is the management of a lower GI bleed?
=> Treat underlying cause just like upper GI Bleed
- Prompt correction of any haemodynamic compromise
- Perform proctosigmoidoscopy in suspected cases of haemorrhoidal bleeding
- Management of unstable patients involves CT or percutaneous angiogram
- ## Stable patient management involves colonoscopy
What are the factors indicating an admission for acute lower GI bleed?
- Age > 60
- Haemodynamic compromise or profuse PR bleeding
- On aspirin or NSAID
- Significant co-morbidity
