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Gwen - GI and General surgery > GI: GI bleeding > Flashcards

GI: GI bleeding Flashcards

1
Q

What is haematemesis?

A

Vomiting blood

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2
Q

What is malaena?

A

Black stools

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3
Q

What are causes of maleana?

A

GI haemorrhage/bleed

  • Peptic ulcer disease
  • Oesophageal varices
  • Oesophagitis
  • Gastritis
  • Mallory–Weiss tear
  • Neoplasm
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4
Q

What is haematochezia?

A

Fresh blood

Note that right sided bleeds tend to present with darker coloured blood than left sided bleeds

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5
Q

Fresh rectal bleed suggests…

A

MASSIVE upper GI bleed - almost presents with signs of shock

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6
Q

What is the mechanism behind malaena?

A

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.

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7
Q

What constitutes “upper” or “lower” GI bleed

A

Upper is proximal to dueodenal junction

Lower is distal to ligament of treitz

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8
Q

What are common causes of upper GI bleeding?

A

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
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9
Q

What drugs can cause upper GI bleeding?

A
  • NSAIDs
  • Aspirin
  • Steroids
  • Thrombolytics
  • Anticoagulants
  • Alcohol
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10
Q

What would you want to ask someone who was presenting with features of an upper GI bleed?

A
  • 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
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11
Q

What symptoms can occur in an acute upper GI bleed?

A
  • Haematemesis
  • Malaenia
  • Dizziness/Psotural Syncope
  • Abdo pain
  • Dysphagia
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12
Q

What signs might indicate someone is having an upper GI bleed?

A
  1. Signs of liver disease - telangiectasia, purpura, jaundice
  2. Signs of shock
  • Hypotension (SBP <100mmHg)/Postural drop >20 mmHg
  • Tacycardia
  • Decreased JVP
  • Decreased Urine output
  • CRT>2s
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13
Q

What bloods would you perform if someone presented in shock from an upper GI bleed?

A
  • FBC - carcinoma, reflux oesophagitis
  • U+E’s
  • Clotting
  • Glucose
  • LFTs - liver disease, varices
  • Crossmatch
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14
Q

How would you manage someone having an acute GI bleed who was shocked?

A

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)

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15
Q

Why would you consider putting in a CVP monitor in someone recieving blood transfusion for an acute GI bleed?

A

To assess transfusion adequacy and overload on the heart

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16
Q

When would you consider transfusion in someone with an upper GI bleed?

A
  • Haemoglobin <80 g/L
  • Patients with active bleeding
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17
Q

What drugs would you want to check for (and stop) in someone having an acute GI bleed?

A
  • NSAID’s
  • Aspirin
  • Clopidogrel
  • Warfarin
  • Consider stopping drugs masking shock features - B-blockers, antiarrythmia, anti-hypertensives (but beta blockers reduces general venous pressure)
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18
Q

What can cause Mallory-Weiss tears?

A

Sudden inicrease in intra-abdominal pressure

  • Heavy coughing
  • Heavy wretching/dry heaves
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19
Q

How would you manage a varcieal bleed?

A
  • IV Terlipressin
  • Broad-spectrum IV antibiotics
  • Endotherapy - variceal ligation/Sclerotherapy
  • Correct any coagulopathies
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20
Q

What can be used to control uncontrolled variceal bleeding?

A
  • Trans-jugular intrahepatic porto-systemic shunt (TIPS)
  • Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies
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21
Q

How would you manage bleeding ulcers?

A
  • 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
22
Q

What scoring systems are used to stratify Upper GI bleeds?

A
  • 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),
23
Q

What is coffee-ground vomit suggestive of?

A

Slow, intermittent bleed

24
Q

What is regarded as the point which distinguishes an upper GI bleed from a lower GI bleed?

A

Ligament of trietz

25
Q

Which does coffee-ground vomit indicate as a cause of haematemesis; peptic ulcers or variceal bleeding?

A

Peptic ulcers

26
Q

What would brisk haematemesis be indicative of as a cause?

A
  • Variceal bleeding
  • Actively bleeding gastro-duodenal ulcer
27
Q

What is haematochezia most commonly associated with; UGIB or LGIB?

A

LGIB - but can be upper in severe UGIB

28
Q

Why might urea be raised in an upper GI bleed?

A

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

29
Q

What proportion of oesophageal varices will rebleed in a year?

A

60%

30
Q

What are the major causes of lower GI tract bleeding?

A
  • 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
31
Q

What are causes of lower GI bleeding?

A
  • 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
32
Q

Investigations lower GI bleed

A

FBC

Stool cultures

Flexible sigmoidoscopy

33
Q

Management of lower GI bleed acutely

A

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.
34
Q

Management of polyps/diverticular disease

A

Colonoscopic haemostatic techniques - adrenalin injection, bipolar coagulation, endoscopic clipping

35
Q

Management of haemorrhoids

A

Band ligation

36
Q

Management of UC

A

Sub-total colectomy (if medical management not effective)

37
Q

Management of severe life threatening bleeding

A

Angiography and mesenteric embolisation

38
Q

What is angiodysplasia?

A
  • 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

39
Q

Clinical features of angiodysplasia

A

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

40
Q

Investigations angiodysplasia

A

Bloods - anaemic? G+S/crossmatch

Imaging - upper GI endoscopy or colonoscopy, small bowel (wire sapsule endoscopy), mesenteric angiography

41
Q

Management angiodysplasia

A

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

42
Q

What is haematochezia?

A

Bright red blood in the stool

43
Q

What is haematochezia indicative of in terms of location of a GI bleed?

A

Lower GI bleed

44
Q

What investigations would you consider doing in someone presenting with features of a lower GI bleed?

A
  • Examination + PR
  • Bloods - FBC, U+E’s, LFT’s, Coagulation, Crossmatch/group and save
  • Consider colonoscopu/sigmoidoscopy/Proctoscopy
  • Consider CT angiography
  • Consider Capsule endoscopy
45
Q

If you were performing protoscopy on someone with features of LGIB, what might you be looking for?

A
  • Haemorrhoids
  • Anorectal disease
46
Q

What would you be looking for on sigmoidoscopy/colonoscopy in someone with LGIB?

A
  • Inflammatory bowel disease
  • Cancer
  • Ischaemic colitis
  • Diverticular disease
  • Angiodysplasia
47
Q

How does chronic GI bleeding tend to present?

A

Iron Deficiency anaemia

48
Q

Causes of chronic GI bleeding

A

Mallory-weiss tear

HHT - hereditary haemorrhagic telangectasia (AVM throughout body eg brain lung liver)

49
Q

What investigations would you consider doing in the context of chronic GI bleeding?

A
  • Upper GI endoscopy
  • Colonoscopy
  • CT colonography/Unprepaired CT
50
Q

What mnemonic can be used to remember causes of Haematemesis?

A

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)
51
Q

So what to do in minor bleed

A

Book for OGD, monitor HB and fluids

52
Q

How to manage a major bleed

A

ABCDE

Then…

mallory weiss: reassure and discharge

peptic ucler: endoscopy - either therapeutic or refer for immediate surgery

varices: consider endoscopic therapy, minessota tube, surgery

Gwen - GI and General surgery (44 decks)

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