GI Bleeds - Upper and Lower Flashcards
What separates the Foregut from the hindgut? What is another name for it?
Ligament of Trietz or DJ flexure
The ligament of Trietz lies on the second part of the duodenum. In Pediatrics and neonatology, what surgical emergency would be this be involved in? Explain.
Volvulus due to the malrotation of the small bowel. It is normally located on the left side but if malrotated, it will be present on the right side (this is the diagnosis of it too)
What 2 arteries are most involved in PUD?
The left gastric and gastroduodenal are most involved in PUD
Spinach, Iron, and Guinness (beer) are known for
Black tarry stools/may mimic malena
What are the 4 most common causes of upper GI bleeding? Give 2 others
PUD (gastric or duodenal ulcer)
Gastritis/oesophagitis
Mallory Weiss Tear
Oesophageal Varices
Recent OGD, Gastric carcinoma, oesophageal carcinoma, Dieulafoy Lesion, pancreatitis (very rare if pseudocyst rupture or erosion of a nearby vessel)
What is a Mallory Weiss Tear?
Where does this typically occur?
Tearing of tissue in the lower oesophagus due to violent coughing or vomiting (including self-induced)
What is a Dieulafoy Lesion
Congenital, large submucosal vessel in the absence of ulcers. May rupture causing bleeding
What is Dyspepsia
Indigestion => uncomfortable upper abdominal pain
What are the clinical features of chronic liver disease? (5) (actual findings on exam)
Jaundice
Ascites
Spider Nevi
Caput Medusae
Hepatomegaly
Gynecomastia
Ecchymosis
What are the features of anemia? (5)
Fatigue
syncope
dyspnea/SOB
Chest pain
Pallor
Dizziness
What are the features of hemorrhagic shock?
Hypotension (incl. orthostatic)
Tachycardia
altered mental state
Tachypnea
QUICK History/Clinical presentation of a patient with an upper GI bleed (up to 10)
Hematemesis/malaena
Hematochezia (fresh bleeding PA)
Abdominal pain (Worse after eating -> PUD/Gastritis vs Duodenal which improves)
Heartburn, reflux, dyspepsia
Weight loss + Dysphagia + night sweats
Features of chronic liver disease (Jaundice, ascites, spider nevi, caput medusae, hepatomegaly, gynecomastia) -> Varices/portal hypertension
Features of Anemia (pallor, fatigue, syncope, SOB/Dyspnea, chest pain) (from blood loss)
!Previous Endoscopy! (iatrogenic)
Medications: Aspirin, warfarin, antiplatelets, NSAIDs, Steroids
Features of Hemorrhagic shock: Hypotension (incl. orthostatic), tachycardia, altered mental state, tachypnea (blood loss)
You ask a patient with suspected PUD about the abdominal pain they have been having. How would you differentiate between a gastric and duodenal ulcer?
Gastric is exacerbated by eating and relieved in duodenal
Gastric will have pain 1-2 hours after eating whereas duodenal is 2-5 hours
Does it awaken you at night. Duodenal more likely to wake the patient up
Duodenal is cyclical
Gastric more associated with weight loss and fe anaemia
QUICK: What are your differentials for an upper GI bleed?
By definition upper GI = oesophagus, stomach and duodenum
Oesophageal: Varices, Malignancy, Ulcer, Oesophagitis, Mallory Weiss Tears
Gastric: Varices, Malignancy, Ulcer, Gastritis, Dieulafoy Lesion
Duodenum: Malignancy, Ulcer, vascular abnormalities (aorto-enteric fistula)
A patient with an AAA has hematemesis and malaena. What is the cause of upper GI bleeding associated with AAA?
Vascular malformations (aorto-enteric fistula)
What X-ray would you order when investigating for an upper GI bleed? Why?
Erect CXR to detect perforation
What techniques may be used to localize bleeding. State in order of specificity
OGD/colonoscopy/sigmoidoscopy
CT angiogram (0.5-1ml/min)
Nuclear technetium (0.1ml/min) but cannot be done in the acute setting
What investigations would you conduct on a patient with a suspected upper GI bleed
Bedside: ECG (A.fib RF) + ABG
Bloods:
FBC w differentials (anemia and platelets), U&E (increased urea:creatinine ratio), LFT (chronic liver disease)
Coag screen (coagulopathy and INR)
ABG - Rule out Ischemia (via lactate)
Group and Cross-match 4 units (good to include, not necessary)
Imaging:
!Erect! CXR
OGD (tears, varices, ulcers, malignancy…) + used in tx
CT/CT angio to localize bleeding source
You are in an emergency station and have to reverse coagulation. The patient is on Warfarin. What are your options? State them in the order of escalation
Vitamin K
FFP - Fresh Frozen Plasma
PCC - Prothrombin Complex Concentrate
What is Octreotide?
Somatostatin analogue which is used in variceal bleeding to reduce splanchnic blood flow. (Used as 1st line and serves the purpose of terlipressin or vasopressin but this has specific reduced splanchnic blood flow)
What is Splanchnic circulation?
Circulation supplying the GI tract, liver, spleen, and pancreas
You are treating a patient with a massive variceal bleed. Giving Octreotide and Terlipressin has not stopped the bleeding. What is your next step? Explain
OGD is the next step but since it is a massive bleed, that would not be suitable. Best course of action is to transfer the patient to theatre and attempt OGD techniques there as anaesthetics are better equipped to manage an emergency and easy to convert to laparotomy if needed. To transfer him to theatre, and SB tube must be inserted
SB tube (Sengstaken-Blakemore) is used. It is an oesophageal and gastric balloon that is inserted. It has several ports with openings at different points (image).
It provides short term Hemostasis but has many complications with rebleeding hence is only used as temporary stabilization
Why is a patient with an SB tube typically intubated?
Intubated to prevent aspiration risk
What is an SB tube?
How will you use it? Walk me through it
SB tube (Sengstaken-Blakemore) is used. It is an oesophageal and gastric balloon that is inserted. It has several ports with openings at different points (image).
It provides short term Hemostasis but has many complications with rebleeding hence is only used as temporary stabilization
1) Sedate the patient and give analgesia (GA in extreme cases)
2) Intubate patient to prevent aspiration risk
3) Inflate the gastric balloon only and suspend on a 1Kg or 1L bag of saline
3) As a last line measure, inflate the Oesophageal balloon
SB tube quick questions:
1) Can an OGD be inserted if a patient has an SB tube?
2) Why do we suspend the SB tube?
3) What is the reason we do not inflate the esophageal balloon
4) What are the top 3 complications of an SB tube?
1) Theoretically yes, realistically wtf
2) To ensure that it will not dislodge and apply pressure on the varices to stop the bleeding
3) Esophageal necrosis
4) Aspiration, Rebleeding, andf oesophageal necrosis
A patient with tachycardia, tachypnea, pallor and altered mental state has arrived to the emergency department. The patient has a 6 day history of hematemesis and bleeding PA. What is your immediate management plan for all cases?
ABC. You must still state the basic steps you will do in each. Here is just the important points
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter (aim >0.5ml/kg/hr)
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)
If >4 units used, activate Major Transfusion protocol
Medications:
1) Correct Coagulation (vit K > FFP > PCC)
2) UPPER GI - PPI: Bolus IV 80mg Omeprazole followed by 40mg BD or IV 8mg/hr for 72hrs if active bleeding
3) IV 1g Tranexamic Acid TDS
4) VARICEAL BLEED: Vasopressin/Octreotide (somatostatin analogue) -> SB tube
Inform: Endoscopy, surgical on call, anesthetist, ICU, theatre
When is the Massive Transfusion Protocol activated?
During transfusion, how is the blood administered? (ratio)
Note that this changes based on hospital
The protocol is activated if either
1) >4 units in <1 hour
2) >10units in <24 hours
3) >50% of total body weight in <3 hours
Blood is transfused with a ratio of 1:1:1 of blood, platelets, and FFP (fresh frozen plasma)
What scoring systems may be used to assess prognosis of a patient with an upper GI bleed?
Rockall score and Blatchford score
What is the Rockall and blatchford scoring systems used for?
Go through the scoring system, cutoffs etc for the Rockall score.
The blatchford scoring system is used to assess the need for urgent treatment and hospital admission before endoscopy
The rockall scoring system is used after endoscopy to evaluate the risk of rebleeding and mortality and can also be used pre-endoscopy to triage whether an OGD needs to be performed urgently or not.
Rock-all score: Age, BP/BPM (shock), Comorbidity, Diagnosis, and Evidence of bleeding
<3 = good prognosis, >8 = bad prognosis
Can also be used to assess triage whether an OGD needs to be performed urgently or not
0/1 = OGD on next available listing, 2+ = Urgent OGD
What is the blatchford score used for?
Used to predict need for endoscopic therapy and discharge
A 55 year old patient presents to the ED with a GI bleed and a history of oesophageal malignancy. On examination his vitals were 65bpm and BP of 140/90. How would you assess his prognosis? When would you slot them in for an OGD?
Rockall score
3 due to malignancy for comorbidities
2 due to upper GI malignancy in diagnosis
Total = 5 => Moderate
2+ => Urgent OGD
An 82 year old women presents to the ED with a history of CHD and 50 pack-year history. an OGD has shown tears in the distal esophagus and an image produced is shown. On examination her vitals were 120bpm and BP of 110/60. How would you assess her prognosis?
Rockall score
Age >80 => 2
CHD => 2
BPM >100 but systolic BP>100 => 1
Mallory Weiss Tear => 0
Spurting vessel => 2
Score = 7 therefore moderate prognosis
A 70 year old gentleman presents to the ED with PUD. He has a history of Alcoholic liver disease. On OGD adherent clots were found in the stomach. On examination, his vitals were 160bpm and BP 90/50. How would you assess his prognosis?
Age 60-79 => 1
Liver disease => 3
Systolic BP<100 => 2
PUD => 1
Adherent clot => 2
Score = 9 => Bad prognosis
What OGD/colonoscopy techniques may be utilized to stop/control bleeding? (especially OGD ofcourse)
Adrenaline injection
Heat probe coagulation (thermal coag)
Argon plasma coagulation
Sclerotherapy (thrombosis due to injection of sclerosant agent)
Banding of varices
What is the therapeutic component for CT angiography (similar concept to OGD techniques)
clip/coil/sclerose identified bleeding vessel
A patient with Variceal bleeding. He has a history of having large tortuous veins in the esophagus. ABCD assessment has already been completed and the patient is somewhat stable but the bleeding persists. What is your management plan and future escalations for this?
1) Octreotide
2) OGD with techniques (adrenaline thermal coag, oesophageal banding…)
3) Angiography with vasopressin injection, clip/coil/sclerose and/or transcatheter embolization
4) TIPS (transjugular Intrahepatic Portosystemic Shunt)
5) Surgery - Laparotomy
What are the indications for surgery for each lower and upper GI bleeds?
In both, this is the last resort
Upper: >6-8 units (of blood) given in <24 hours and still hemodynamically unstable
Lower: >4–6 units given in <24 hours and still hemodynamically unstable
Define Lower GI bleeding
Abnormal hemorrhage into lumen of bowel from source distal to the ligament of Treitz.
Give 2 examples of Anorectal disease
Hemorrhoids, anal fissure, fistula
The colon is the source of 95% of lower GI bleeds whereas the small bowel is only responsible for 5%. What are your differentials for a lower GI bleed for both the Colon (6) and Small intestine (4)
Colon:
Diverticular disease (40%)
Ischaemic, Inflammatory, infectious, Radiation colitis (30%)
Anorectal disease => hemorrhoids, anal fissure, fistula (10%)
Malignancy (10%)
Polyps!!!!!!!!! (10%)
Angiodysplasia (10%)
IBD
Small bowel: Angiodysplasia, Crohn’s, Meckel’s diverticulum, Aortoenteric fistula (AAA complication), Ulcers/erosions, Any upper GI cause
QUICK History/Clinical presentation of a patient with a lower GI bleed (up to 8)
Malaena vs Hematochezia (fresh bleeding PA)
Painless bleed (diverticular disease) vs Painful bloody diarrhea (IBD)
Tenesmus (IBD)
Weight loss + night sweats (Malignancy)
Features of Anemia (pallor, fatigue, syncope, SOB/Dyspnea, chest pain) (from blood loss)
!Previous colonoscopy/sigmoidoscopy! (iatrogenic)
Medications: Aspirin, warfarin, antiplatelets esp clopidogrel, NSAIDs, Steroids
Features of Hemorrhagic shock: Hypotension (incl. orthostatic), tachycardia, altered mental state, tachypnea (blood loss)
What investigations would you conduct on a patient with a suspected lower GI bleed
Bedside: ECG (A.fib RF) + NGT aspirate (distiguish upper vs lower)
Bloods:
FBC w differentials (anemia and platelets), UandE (increased urea:creatinine ratio), LFT (chronic liver disease)
Coag screen (coagulopathy and INR)
Group and Cross-match 4 units (good to include, not necessary)
ABG - Rule out Ischemia (via lactate)
Imaging:
Colonoscopy/Sigmoidoscopy(tears, varices, ulcers, malignancy…) + used in tx
Note: only effective in mild/moderate bleeding because too much blood to see in severe bleeding
CT/CT angio to localize bleeding source
A patient with painless hematochezia arrives to the ED. ABCD assessment has already been completed and the patient is somewhat stable but the bleeding persists. It is confirmed to be a lower GI bleed. What is your management plan and future escalations for this?
Once ABCD assessment has been completed
1) Therapeutic Colonoscopy employing same technique as OGD
2) Mesenteric Angiography employing Vasopressin injection or transcatheter embolization
3) Surgery if hemodynamically unstable with >4-6 units of blood given in <24hrs
A patient with Hematochezia cannot have the source localized even with CT angiogram and bleeding is ongoing despite all efforts to treat. Upper GI bleeding has been ruled out via OGD. 5 units of blood have been given to the patient so far since admission 16 hours ago
With all other treatment options failed (therapeutic colonoscopy, mesenteric angiography vasopressin injection, and embolization), If the source is now localized, what is your surgical management?
If the source is still not localized, how will you surgically manage?
After all other treatment options have failed and the patient has received >4-6 units of blood (6-8 in upper) in <24 hours => hemodynamically unstable, surgery is the next step
If bleeding source is localized => adrenaline injection, clip, oversow and ommental patching and finally Resection of bleeding segment
If not localized => Total colectomy with ileoanal anastomosis (temporary ileostomy)
Why is omental wrapping used for large tears as oppose to pressure and suture used in small tears?
Omental wrapping prevents herniation
What type of beta blockers would be used in the treatment or variceal bleeding? Give the best example.
Non-selective. It is also used to prevent what causes this which is cirrhosis and portal hypertension.
E.g. Propanalol
After a massive Upper GI bleed. What will you send the patient home on?
H.Pylori eradication => triple therapy with PAC500 or PMC250
When managing a patient with an upper GI bleed it is important first to determine if the patient is stable or unstable and second to determine if it is a variceal blled or a non-variceal bleed. In what circumstance will you administer a prokinetic? Give me 3 examples
What about antibiotics
Prokinetics should be administered if there is a non-variceal bleed to evacuate the blood from the stomach for endoscopy
Erythromycin
Metoclopramide
Domperidone
Antibiotics on the other hand should be given to those with a Variceal bleed as they may be decompensated
What classification is used to determine the severity of an upper GI bleed based on endoscopy findings? Go through it (not rockall)
Forrest Classification it indicates the risk of rebleeding prognostically
Ia - Spurting haemorrhage (2pts on rockall)
Ib - Oozing haemorrhage
IIa - Non-bleeding visible vessel
IIb - Adherent clot (2pts on rockall)
IIc - Flat pigmented spot
III - Clean base ulcer
Remember that the worst is I and best is III
When treating an upper GI bleed (OGD) dual therapy is always better than monotherapy. What is meant by dual therapy?
Dual therapy is Adrenaline injection + Thermal or mechanical techniques.
Monotherapy is only one of them.
Dual therapy has a reduced risk of rebleeding, reduced need for surgery and reduced mortality
Are outcomes better with surgery or IR embolization?
Based on a meta-analysis in the BJS, surgery has generally better outcomes
In a patient with a large bleeding duodenal ulcer, which is the most appropriate operation to be performed when endoscopy was unsuccessful in haemorrhage control?
What if that fails
Laparoscopy to oversow of the gastroduodenal ulcer via graham patch repair (esp if large to prevent herniation)
Then open laparotomy which can include a partial or total gastrectomy/removal of diseased segment
What is rectorrhagia?
Fresh Bleeding PA without stools
Patient presents with lower GI bleeding and pain specifically on the left side. What are the 2 most likely dx?
Diverticulitis
Ischaemic colitis
A patient presents with lower GI bleeding and has a history of A.fib. What is the most important question to ask?
are they on anti-coagulants?
A patient presents to the ED with a lower GI bleed. What is the name of the scoring system used to determine if the patient should be discharged or admitted?
What are the 3 main components in it (very general)
How would you interpret the score?
Oakland score is based on
1) Patient factors (age, sex)
2) History and exam findings (previous admission, DRE)
3) Vitals and Hb
Score <9 = discharge (which means GP referral for OPD endoscopy and followup)
Score 9+ = Admit
What transfusion policy is used in both upper and lower GI bleeds?
A) Restrictive
B) Liberal
C) Aggressive
A - Restrictive (dont forget to contact ICU)
What is the door to CT angio time in an upper or lower GI bleed?
60 minutes ideally
Angiography (not the same as CT angiography which is done first and must be done within 60 minutes if possible) is typically conducted with which arteries for a lower GI bleed
SMA or IMA
Unlike an upper GI bleed, a lower GI bleed rarely needs surgery. What are some indications for a lower GI bleed surgery?
1) Haemodynamically unstable despite previous step-ups
2) Bleeding duration >72 hours
3) Transfusion >6-8 units in 24 hours
4) Rebleed after cessation for >24 hours
5) Ischemia
6) Peritonitis
