GI: GI bleeding Flashcards
What is haematemesis?
Vomiting blood
What is malaena?
Black stools
What are causes of maleana?
GI haemorrhage/bleed
- Peptic ulcer disease
- Oesophageal varices
- Oesophagitis
- Gastritis
- Mallory–Weiss tear
- Neoplasm
What is haematochezia?
Fresh blood
Note that right sided bleeds tend to present with darker coloured blood than left sided bleeds
Fresh rectal bleed suggests…
MASSIVE upper GI bleed - almost presents with signs of shock
What is the mechanism behind malaena?
Bleeding from any cause in the upper gastrointestinal tract can result in melaena. It is often said that bleeding must begin above the ligament of Treitz; however, this is not always the case.
The black, foul-smelling nature of the stool is due to the oxidation of iron from the haemoglobin, as it passes through the gastrointestinal tract.
What constitutes “upper” or “lower” GI bleed
Upper is proximal to dueodenal junction
Lower is distal to ligament of treitz
What are common causes of upper GI bleeding?
OESOPHAGEAL
- Oesophagitis - inflammation og oesophagus eg GORD, infections, eosinophilic oesophagitis
- Oesophageal varcies - result of portal hypertension, large volumes (oesophageal vein and gastric vein both drain to portal vein)
- Mallory-Weiss tears - tear of lower oesophagus, bleeding stops spontaneously in 80-90%
GASTRIC
- Gastritis/Gastric ulcers - eg NSAIDs, alcohol
- Peptic ulcers - most common (often associated with aspirin/NSAID ingestion)
- Malignancy - oesophageal tumours, polyps/gastric adenomas, malignant tumours (gastric carcinoma/lymphoma)
- Dieulafoys’s disease - spontaneous large bleeds
DUODENAL
- Ulcers - prominent melena
- Duodenitis
- Artoduodenal fistula - massive haematemsis + PR bleed
OTHER
- No Obvious cause
- Drugs
What drugs can cause upper GI bleeding?
- NSAIDs
- Aspirin
- Steroids
- Thrombolytics
- Anticoagulants
- Alcohol
What would you want to ask someone who was presenting with features of an upper GI bleed?
- Past GI bleeds
- Dyspespsia/known ulcers
- Known liver disease/oesophageal varices
- Dysphagia
- Vomiting
- Weight loss
- Drugs and alcohol use
- Serious comorbidities - CVS, Resp, hepatic/renal, malignancy
What symptoms can occur in an acute upper GI bleed?
- Haematemesis
- Malaenia
- Dizziness/Psotural Syncope
- Abdo pain
- Dysphagia
What signs might indicate someone is having an upper GI bleed?
- Signs of liver disease - telangiectasia, purpura, jaundice
- Signs of shock
- Hypotension (SBP <100mmHg)/Postural drop >20 mmHg
- Tacycardia
- Decreased JVP
- Decreased Urine output
- CRT>2s
What bloods would you perform if someone presented in shock from an upper GI bleed?
- FBC - carcinoma, reflux oesophagitis
- U+E’s
- Clotting
- Glucose
- LFTs - liver disease, varices
- Crossmatch
How would you manage someone having an acute GI bleed who was shocked?
ABCDE
- Protect airway, give O2
- Circulation assessment + 2 large bore cannulae
- Rapid crystalloid infusion - Consider Blood transfusion if severe shock
- Correct clotting abnormalities
- Catheterise and monitor urine output
- 15 minute obervations
- Urgent endoscopy - urgently indicated in patients with shock, continued bleeding or suspected varices
- Consider surgery if bleeding persists
Can use a minnesota tube (balloon)
Why would you consider putting in a CVP monitor in someone recieving blood transfusion for an acute GI bleed?
To assess transfusion adequacy and overload on the heart
When would you consider transfusion in someone with an upper GI bleed?
- Haemoglobin <80 g/L
- Patients with active bleeding
What drugs would you want to check for (and stop) in someone having an acute GI bleed?
- NSAID’s
- Aspirin
- Clopidogrel
- Warfarin
- Consider stopping drugs masking shock features - B-blockers, antiarrythmia, anti-hypertensives (but beta blockers reduces general venous pressure)
What can cause Mallory-Weiss tears?
Sudden inicrease in intra-abdominal pressure
- Heavy coughing
- Heavy wretching/dry heaves
How would you manage a varcieal bleed?
- IV Terlipressin
- Broad-spectrum IV antibiotics
- Endotherapy - variceal ligation/Sclerotherapy
- Correct any coagulopathies
What can be used to control uncontrolled variceal bleeding?
- Trans-jugular intrahepatic porto-systemic shunt (TIPS)
- Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
How would you manage bleeding ulcers?
- Haemostatic therapy - 2 out of 3/3 out of 3 of clips, cautery or adrenaline
- Post endoscopic PPI’s
- Consider H. Pylori erdication therapy
- Discontinue causative therapies - NSAIDs, aspirin
What scoring systems are used to stratify Upper GI bleeds?
- Glasgow-Blatchford bleeding score - initial risk assessment of acute upper GI bleed
- Rockall score - identify patients at risk of complications following acute upper GI bleed (predicts mortality and risk of rebleed) variables are age, shock, co-morbidity, diagnosis (post OGD),
What is coffee-ground vomit suggestive of?
Slow, intermittent bleed
What is regarded as the point which distinguishes an upper GI bleed from a lower GI bleed?
Ligament of trietz
Which does coffee-ground vomit indicate as a cause of haematemesis; peptic ulcers or variceal bleeding?
Peptic ulcers
What would brisk haematemesis be indicative of as a cause?
- Variceal bleeding
- Actively bleeding gastro-duodenal ulcer
What is haematochezia most commonly associated with; UGIB or LGIB?
LGIB - but can be upper in severe UGIB
Why might urea be raised in an upper GI bleed?
As blood passes through the small bowel and is partially digested, it can result in an elevated urea and urea/Cr ratio - equivalent to a large protein meal
What proportion of oesophageal varices will rebleed in a year?
60%
What are the major causes of lower GI tract bleeding?
-
Diverticular disease
- Most occur in simoid/descending but most bleeding occur in ascending
- RF = constipation
- Classically painless
-
Colitis
- Ischaemia
- Inflammatory - crohns/UC
- Infectious - campylobacter, salmonella, shigella, E. Coli 0157
-
Neoplasia
- Weight loss
- Esp colorectal cancer
-
Haemorrhoids
- Internal/external/fissures
-
Angiodysplasia
- Most occur in caecum/ascending colon
- Smooth muscle - contracted - dilated veins - AF formation
What are causes of lower GI bleeding?
- Diverticulitis
- Colonic carcinoma
- Meckel’s Diverticulum
- Ischaemic colitis
- Polyps
- Crohn’s/Colitis
- Haemorrhoids
- Anal fissure
- Angiodysplasia
-
Artoenteric fistula
- Aorta to small bowel (small bleeds to massive haemorrhages
- EMEREGENCY
Investigations lower GI bleed
FBC
Stool cultures
Flexible sigmoidoscopy
Management of lower GI bleed acutely
ABCDE
A: Airway
B: Breathing and ventilation
C: Circulation and haemorrhage control
- IV access - large bore cannulae and take blood (FBC, LFTs, Us+Es, clotting screen, cross match 4-6 units)
- IV fluids (to restore intravascular volume while waiting on cross match)
- Urinary catheter
- Organise CXR, ECG and check ABG
- Correct clotting
- Monitor HR, BP and CVP
- Arrange urgent endoscopy - colonoscopy/sigmoidoscopy (IBD, polyps, diverticular disease, colon cancer, vascular elsion), protoscopy (haemorrhoids, anorectal disease)
- Arrange urgen radiography -
angiography, may show bleeding point/vascular abnormalities.
Management of polyps/diverticular disease
Colonoscopic haemostatic techniques - adrenalin injection, bipolar coagulation, endoscopic clipping
Management of haemorrhoids
Band ligation
Management of UC
Sub-total colectomy (if medical management not effective)
Management of severe life threatening bleeding
Angiography and mesenteric embolisation
What is angiodysplasia?
- MOST COMMON VASCULAR ABNORMALITY OF THE GI TRACT
- Caused by formation of arteriovenous malformations between previously healthy blood vessles.
- ACQUIRED = beings as decreased submucosal venous drainage in the colon, giving rise to dilated and torturous veins. Results in loss of pre-capillary sphincter competanct and in turn the formation of small arterio-venous communications
- CONGENITAL - eg HHT
It resembles telangiectasia and development is related to age and strain on the bowel wall. It is a degenerative lesion, acquired, probably resulting from chronic and intermittent contraction of the colon that is obstructing the venous drainage of the mucosa
Clinical features of angiodysplasia
Rectal bleeding - majority is just painless occult, acute haemorrhage, asymptomatic diagnosed on colonoscopy
Elderly patinets with chronic undiagnosed angiodysplasia may present with symptoms of anaemia
Investigations angiodysplasia
Bloods - anaemic? G+S/crossmatch
Imaging - upper GI endoscopy or colonoscopy, small bowel (wire sapsule endoscopy), mesenteric angiography
Management angiodysplasia
In persistant/severe
- Enscopy - argo plastic coagulation
- Mesenteric angiography (used for small bowel lesions that can’t be treated endoscopically)
Indications for surgery = continuation of severe bleeding despite antiographic and endoscopic management, severe/acute life threating bleed, multiple lesions that cant be treated medically
What is haematochezia?
Bright red blood in the stool
What is haematochezia indicative of in terms of location of a GI bleed?
Lower GI bleed
What investigations would you consider doing in someone presenting with features of a lower GI bleed?
- Examination + PR
- Bloods - FBC, U+E’s, LFT’s, Coagulation, Crossmatch/group and save
- Consider colonoscopu/sigmoidoscopy/Proctoscopy
- Consider CT angiography
- Consider Capsule endoscopy
If you were performing protoscopy on someone with features of LGIB, what might you be looking for?
- Haemorrhoids
- Anorectal disease
What would you be looking for on sigmoidoscopy/colonoscopy in someone with LGIB?
- Inflammatory bowel disease
- Cancer
- Ischaemic colitis
- Diverticular disease
- Angiodysplasia
How does chronic GI bleeding tend to present?
Iron Deficiency anaemia
Causes of chronic GI bleeding
Mallory-weiss tear
HHT - hereditary haemorrhagic telangectasia (AVM throughout body eg brain lung liver)
What investigations would you consider doing in the context of chronic GI bleeding?
- Upper GI endoscopy
- Colonoscopy
- CT colonography/Unprepaired CT
What mnemonic can be used to remember causes of Haematemesis?
GUM BLEEDING
- Gastritis
- Ulcer (peptic)
- Mallory-Weiss (tear of the lower oesophageal mucosa)
- Biliary (haemobilia – post cholecystectomy/liver biopsy)
- Large varices
- Esophagitis (Oesophagitis)
- Entero-aortic fistula (after repair of aortic aneurysm)
- Duodenitis (peptic ulcer)
- Inflammatory bowel disease (rare)
- Neovascularisation (rare)
- Gastric carcinoma (unusual)
So what to do in minor bleed
Book for OGD, monitor HB and fluids
How to manage a major bleed
ABCDE
Then…
mallory weiss: reassure and discharge
peptic ucler: endoscopy - either therapeutic or refer for immediate surgery
varices: consider endoscopic therapy, minessota tube, surgery
