GI/GEN - Upper & Lower GI Bleeding Flashcards
Blood Supply of GI Structures
Oesophagus
Stomach
Duodenum
Small Intestines
1.) Oesophagus
- thoracic part: thoracic aorta + inferior thyroid artery
- abdominal part: left gastric artery and left inferior phrenic artery
2.) Stomach - Celiac Trunk (T10)
- lesser curve: R (CH) + L gastric artery
- greater curve: R (CH) + L gastroepiploic (splenic)
3.) Duodenum - Celiac + SMA (L1)
- proximal 1/3: celiac trunk (gastroduodenal) via the superior pancreaticoduodenal artery
- distal 2/3: SMA via inferior pancreaticoduodenal
- suspensory ligament of the duodenum (duodeno-jejunal flexure) separates upper and lower GI bleeds
4.) Small Intestines - SMA
- jejunal and ileal arteries supplies respective parts
- ascending colon: right colic artery
- transverse colon: middle colic artery
- ileocolic artery supplies appendix, caecum, and parts of the ascending colon and ileum
Causes of Haematemesis
Gastroduodenal Ulceration (most common)
Oesophageal Varices
Mallory-Weiss Tear
Oesophagitis
Others
1.) Gastroduodenal Ulceration - emergency
- post-prandial epigastric pain w/ nausea + bloating
- most common on lesser curve of the stomach (20%) or the posterior duodenum (40%)
- bleeding worse w/ duodenal (gastroduodenal artery)
- ulcers at the gastroduodenal junction compromise the common hepatic/gastroduodenal artery
- gastric ulcers rarely perforate due to intro of PPIs so one must suspect cancer in perforated gastric ulcers
2.) Oesophageal Varices - emergency
- dilation of porto-system venous anastomosis
- most common cause is portal hypertension due to alcoholic liver disease so ask about h/o alcohol abuse
3.) Mallory-Weiss Tear
- forceful vomiting causes a tear in epithelial lining of oesophagus causing a small bleed
- mostly benign and resolves spontaneously
4.) Oesophagitis
- often due to GORDs, also infections (candida), medication (e.g. bisphosphonates), radiotherapy, ingestion of toxic substances, Crohn’s
5.) Others
- gastritis, gastric malignancy, Meckel’s diverticulum, vascular malformations (angiodysplasia)
Investigating Haematemesis
Clinical Features/History Taking
Routine Bloods
Imaging x3
Glasgow-Blatchford Bleeding Score (GBS)
Other Scoring Systems
1.) Clinical Features/History Taking
- timing, frequency, and volume of bleeding
- coffee-ground vomit suggests bleeding has stopped
- h/o of GORDs, dysphagia or odynophagia
- PMH of smoking and alcohol
- DH: use of steroids, NSAIDs, anticoagulants, bisphosp…
2.) Investigations - FBC, U+Es, LFT, clotting, VBG, G+S
- acute bleeds may not show anaemia but LFTs may show underlying liver damage as a potential cause
- VBG is the quickest way to get Hb result
- ↓Hb + ↑urea:creatinine ratio is indicative of an upper GI bleed
- G+S (or crossmatch) as might need surgery
- C-13 urea breath test for H.pylori (should stop PPI 2wks before and antibiotics 4wks before)
3.) Imaging - OGD, CXR, CT-Abdo
- OGD (definitive): w/in 24hrs if stable, ASAP if unstable
- eCXR: pneumoperitoneum if perforated peptic ulcer
- CT Abdo w/ IV Contrast: assesses active bleeding if endoscopy is unremarkable or unsuitable
4.) GBS - risk-stratify patients w/ upper GI bleed
- score >6 suggests >50% risk of needing intervention (blood transfusion or therapeutic endoscopy)
- scoring criteria: ↑urea, ↓Hb, ↓BP, ↑HR, melena, syncope, hepatic failure, cardiac failure
- determines who is managed in outpatients
5.) Other Scoring Systems
- AIMS65: risk of mortality
- Rockall: death/re-bleeding risk (post-endoscopy)
Management of Haematemesis
Rapid A-E Assessment
Oesophageal Varices
Peptic Ulcer Disease
Upper GI Endoscopy (OGD)
Angio-Embolisation
1.) ABCDE Assessment
- start fluid resus if needed and crossmatch blood
2.) Oesophageal Varices
- IV fluid resus (unstable), then blood transfusion
- ↓bleeding: IV terlipressin (vasopressor) if no IHD/PVD (somatostatin analogues e.g. octreotide as alternative)
- prophylactic IV Co-amoxiclav 1.2g TDS for 24hrs then switch to PO for 48hrs to complete prophylaxis for 72 hours
- referral for therapeutic OGD for definitive treatment
- long term/prevention: propranolol, repeated banding
3.) Peptic Ulcer Disease (Gastric Ulcers)
- adrenaline injections and cauterisation of bleeding
- carbon-13 urease breath test best for detecting H pylori, PPI (2wks) and antibiotics (4wks) should be stopped before testing
- IV PPI therapy +/- H.pylori eradication therapy
- referral for therapeutic OGD
4.) OGD - done for most cases where there’s a range of therapeutic options depending on underlying cause
- gastric ulcers: clips, thermal coagulation
- varicies: endoscopic banding, TIPSS (intra-hepatic shunt), balloon tamponade (Sengstaken tube, reduces pressure, not definitive)
5.) Angio-Embolisation - percutaneous embolism of the bleeding vessel (gastroduodenal most common due to ulcer most commonly at the posterior duodenum
Melaena
What is it?
Causes
Investigations
Management
1.) What is it? - black stools due to upper GI bleeding
- tarry colour and offensive smell due to to alteration and degradation of blood by intestinal enzymes
2.) Causes - similar to haematemesis
- peptic ulcer disease, oesophageal varices
- oesophageal or gastric malignancies (GIST)
- others: gastritis, oesophagitis, Mallory-Weiss tear, Meckel’s diverticum, vascular malformations e.g GAVE (gastric antral vascular ectasia)
3.) Investigations
- DRE, full abdo exam, routine bloods, ABG
- OGD (definitive), may use colonoscopy or capsular endoscopy if OGD inconclusive
- CT abdo w/ IV contrast assesses active bleeding
4.) Management
- A-E assessment, endoscopy when stable
- blood products transfused to haemodynamically unstable or patients with low Hb (<70)
- upper GI malignancies require biopsies
Causes of Haematochieza (Rectal Bleeding)
Origin
Diverticulosis
Haemorrhoids
Malignancy
Other Causes
1.) Origin - can be lower GI or potentially upper GI
- large haematochieza + haemodynamically instability is an upper GI bleed until proven otherwise
2.) Diverticulosis - most common cause
- diverticular disease bleeds are painless whilst diverticulitis associated bleeds are often painful
3.) Haemorrhoids - mass + pruiritus + fresh PR bleed
- blood is on stool surface rather than mixed with it
- large haemorrhoids can thrombose –> very painful
4.) Malignancy - any PR bleed in elderly, colorectal cancer must be suspected
5.) Other Causes
- colitis: ischaemic, infective, or ulcerative
- Crohn’s disease, anal fissure, proctitis, polyps,
- angiodysplasia (vascular malformation)
Investigating Haematochieza
Clinical Features
Relation with Stool
Investigations
Imaging
Oakland Score
1.) Clinical Features - either stable or unstable
- volume, duration, frequency, colour, mucus?
- associated sx: hypovolaemic sx, pain, haematemesis,
- red flags: change in bowel habit, weight loss, iron deficiency anaemia, tenesmus
- FH of bowel cancer or IBD
2.) Relation with Stool
- mixed: lesion is proximal to sigmoid colon
- streaked: sigmoid or anorectal source of bleeding
- immediately after: anal condition e.g. haemorrhoids
- separate: diverticulosis, IBD, angiodysplasia, cancer
- only on toilet paper: haemorrhoids or anal fissure
3.) Investigations
- abdo exam and DRE, routine bloods, stool cultures
- urgent CT angio in haemodynamically unstable
4.) Imaging - for all patients
- flexible sigmoidoscopy –> colonoscopy
- OGD if colonoscopy is normal
5.) Oakland Score - stratifies patients
- determines if outpatient management is feasible
- age, sex, previous admissions, PR findings, HR, sysBP, Hb conc
Management of Haematochieza
Spontaneously Settle
Unstable Patients
Endoscopic Haemostasis Methods
Arterial Embolisation
Surgical Intervention
1.) Spontaneously Settle - 85-95% of cases
- young, stable patients can be discharged and investigated as an outpatient
2.) Unstable Patients - A-E assessment
- urgent resus w/ IV fluids and blood products
- transfusion of packed RBCs if Hb <70
- reverse any anti-coagulation, tranexamic acid
3.) Endoscopic Haemostasis Methods
- injection: usually diluted adrenaline
- thermal devices: e.g. electrocoagulation
- mechanical: endoscopic clips, band ligation
4.) Arterial Embolisation - used in patients with an identified large bleeding point on an angiogram
5.) Surgical Intervention - rare, last resort
- segmental resection or subtotal colectomy
