GI Emergencies Flashcards
In which ways can an acute GI bleed present?
Haematemesis, coffee ground vomit, and melaena
Which is more common - an upper GI bleed or a lower GI bleed?
Upper, by about 4 times.
What is the most important factor in prognosis following a GI bleed?
The size of the vessel affected
What is the most common cause of an acute upper GI bleed?
Peptic ulcers and oesophago-gastric varices.
Other than peptic ulcers and oesophageal varices, what are some causes of an upper GI bleed?
- Gastritis
- Duodenitis
- Portal hypertensive gastropathy
- Malignancy
- Mallory-Weiss tear
- Vascular malformation
If peptic ulcer disease is suspected as the cause of an upper GI bleed, what factors in the history might support that diagnosis?
- Alcohol abuse
- Chronic renal failure
- NSAIDs
- Increasing age
- Low socio-economic class
- Hx of H. pylori
How can the severity of a GI bleed be assessed initially?
By the extent of the blood loss and degree of shock.
What does haematemesis usually indicate?
Active haemorrhage
What does coffee-ground vomit usually indicate?
Bleeding has ceased, is modest, or lower upper GI.
What does melaena usually indicate?
Upper GI bleed, but also possible to be from small bowel or right side of colon.
What is a Mallory-Weiss tear?
A tear of the lower oesophagus usually secondary to chronic excessive coughing or vomiting
What signs of shock due to an acute bleed might be found on examination?
Hypotension Tachycardia Pallor Postural drop Cool extremities Chest pain Confusion Oliguria
If an acute bleed has a chronic background, what additional signs might be elicited on examination?
Pallor and signs of anaemia
Evidence of dehydration
Stigmata of liver disease or signs of a tumour
What is the primary investiagtion with an acute GI bleed?
Endoscopy - oesophagogastroduodenoscopy for upper, and flexible sigmoscopy for lower GI bleed.
How quickly should endoscopy be performed on a pt with an acute GI bleed?
Immediately after resus if severe and acute, but within 24 hours of admission for all other UGI bleeds.
Which blood tests should be ordered on a pt with an acute gi bleed? Justify each answer.
- FBC mainly for Hb
- Cross match - 2-6 units
- Coagulation profile and INR
- LFTs (underlying liver disease)
- U&Es (nitrogen:creatitine ratio, AKI)
What use would a CXR be in a pt with an acute upper GI bleed?
Can be used to exclude perforated viscus/ileus if performed upright.
Also can rule out aspiration and perforated oesophagus.
What is the way to remember management for an acute GI bleed?
8Cs
What are the 8Cs of an acute GI bleed?
- Crossmatch
- Cannulate x2
- Coagulation screen
- Crystalloids
- Catheter
- Cold-prick drugs (warfarin etc)
- Camera (OGD)
- Call surgeons and for help!
What are the 2 scoring systems for acute upper GI bleeds?
- Blatchford at first assessment
- Rockall score after endoscopy
A score of what on the Blatchford risk assessment indicates a pt needs intervention?
Anything more than zero.
A score of what on the Rockall scale indicates a pt should be investiagted with endoscopy?
Anything more than zero.
What techniques are used to treat non-variceal bleeds once they are visualised on endoscopy?
- Clips +/- adrenaline
- Thermal coag + adrenaline
- Fibrin/thrombin + adrenaline
What techniques are used to treat variceal bleeds once they are visualised on endoscopy?
- Terlipressin at presentation
- Balloon tamponade
- Band ligation
What benign anorectal pathology might cause a PR bleed?
Haemorrhoids
Anal fissure
Fistula-in-ano
What benign colonic pathology might cause a PR bleed?
Diverticular disease
IBD
What malignant/premalignant pathology might cause a PR bleed?
Polyps
Colorectal or anal cancer
How can a PR bleed present?
Anywhere on the spectrum between occult, moderate, and massive bleeding.
What red flags with PR bleeding would make you suspect a malignant cause?
Unexplained weight loss Change in bowel habit Tenesmus FHx PMHx
How does retal bleeding tend to present wrt the amount of blood?
1 of 3 ways:
- Occult i.e. with anaemia
- Moderate e.g. small amounts visible in stool
- Massive bleeding with signs of shock
Where is it likely to have come from if a PR bleed is:
- Bright fresh blood?
- Blood mixed with stool?
- Tar-like faeces?
- Lower down in GI tract
- Higher GI tract, middle ground
- Upper GI tract
O/E of a pt with PR bleeding, what focussed points can be examined?
- Pallor/anaemia
- Signs of shock
- Cachexia/weight loss
- Abdominal masses
- PR for any obvious pathology
What baseline bloods are important for GI bleeds?
- FBC
- Iron studies
- Clotting
- LFTs
Which additional test can be performed in a young pt with a GI bleed, and why?
Faecal calprotectin as it is a useful screen for IBD.
What are the 2 categories of abdominal trauma?
Blunt and penetrating
Which organs are most commonly dama n blunt abdominal trauma?
Liver and spleen
What mechanisms are common for blunt abdominal trauma?
Blow from an external object e.g. seatbelt
Deceleration forces
I.e. very common in RTCs
What might cause trauma penetrating the abdomen?
Gunshot, shrapnel, stab wound, RTC… loads of ways
Which observation measured out of hospital is a sign of more significant intra-abdominal injuries?
Hypotension
If a patient has had blunt trauma to the abdomen, but has no signs on examination, can we send them home?
No - they need serial examinations and imaging to exclude occult injuries.
What is the seat-belt sign?
Bruising across site of lap portion of seatbelt that has high levels of association with abdominal organ damage.
Which organ is most at risk in children who have the seatbelt sign?
Pancreas
Following abdomina trauma, what might abdominal breathing pattern indicate?
Spinal cord injury
What is Cullen’s sign?
Periumbilical eccymosis indicating retroperitoneal haemorrhage
A patient who has been in an RTC has abdominal trauma. They have signs of peritonitis. What is the cause likely to be if this is noted:
- immediately?
- 5 hours after the incident?
- Leakage of intestinal contents
2. Intra-abdominal haemorrhage
What bedside tests are important in abdominal trauma?
- Glucose levels
- Urinalysis
- Pregnancy test
Which imaging investiagtion is used in haemodynamically unstable trauma patients?
FAST - Focused abdominal sonography for trauma
Which imaging investiagtion is used in haemodynamically stable trauma patients?
CT abdomen
Why is acute pancreatitis so painful?
Inflammation of pancreas causes exocrine enzyme release which autodigests the pancreas.
What are the top 2 causes of acute pancreatitis?
Gallbladder disease
Excess alcohol consumption
How do gallstones cause pancreatitis?
Blockage of the bile duct, which creates back-pressure into the pancreatic duct
What is the acronym for the causes of pancreatitis?
GET SMASHED
What are the causes of pancreatitis according to the GET SMASHED acronym?
Gall stones Ethanol Trauma Steroids Mumps Autoimmune Scorpion poison Hypercalcaemia/Hypercholesterolaemia/Hypothermia ERCP Drugs
Which drugs can cause acute pancreatitis?
Thiazides
Sodium valproate
Azathioprine
A man comes to A&E with sudden onset severe abdominal pain an vomiting, which radiates to his back. What blood test should we 100% do?
Amylase!
A man comes to A&E with sudden onset severe abdominal pain an vomiting, which radiates to his back. How should this patient be assessed initially?
ABCDE assessment
A man comes to A&E with sudden onset severe abdominal pain an vomiting, which radiates to his back. What sign can we look for on examination that might suggest origin in the bile duct?
Presence of jaundice
What are the worrying signs on examination of a patient with ?pancreatitis?
- Gross hypotension
- Pyrexia
- Tachypnoea
- Ascites
- Pleural effusion
- Cullen’s sign or Grey Turner’s sign
What amylase suggests acute pancreatitis?
Rasied 3 times upper limit of normal
A man comes to A&E with sudden onset severe abdominal pain an vomiting, which radiates to his back. What are your top differentials that need ruling out?
Pancreatitis
Small bowel perforation/obstruction
Ruptured or dissecting AA
Atypical MI
How is the severity of pancreatitis measured?
Using the Glasgow score
How does the Glasgow score measure prognosis in pancreatitis?
Point for:
- Age over 55
- WCC over 15
- Urea over 16
- Glucose over 10
- pO2 under 8
- Albumin under 32
- Calcium under 2
- LDH over 600
- AST/ALT over 200
3 or more indicates severe pancreatitis
How should mild pancreatitis cases be managed?
Supportively: -Analgesia -IV fluids if NBM Abx if specific infection present NG tube if severe vomiting Treat the cause e.g. bile duct clearance if gallstones cause.
How should severe pancreatitis cases be managed?
- ITU/HDU admission
- IV abx for pancreatic necrosis
- Enteral nutrition (NG tube inserted into the jejunum)
- Surgery for infection and necrosis
What are the complications of acute pancreatitis?
- Pancreatic necrosis
- Infected necrosis
- Acute fluid collections
- Pancreatic abscess
- Acute cholecystitis
- Systemic complications
