GI Haemorrhage Flashcards
describe melaena
black, thick, sticky, semi liquid stool
what is vomiting blood called
haematemesis
what are the most common causes for a GI bleed
duodenal ulcer, gastric erosions, gastric ulcer, varices
what is a mallory-weiss tear
distal oesophageal tear due to repeated vomiting
what is the immediate treatment for a GI haemorrhage
resuscitation, ABC: airway protection, oxygen, IV access, fluids
why must a grey IV access cannula be used
as it is the largest bore, 2 can maintain pace of GI bleed
what is the 100 rule
used to assess the severity- people in a poor prognostic group systolic BP < 100mmHg pulse > 100 bpm Hb < 100 age > 60 comorbid disease postural hypotension
what else might affect people ability to compensate for a GI bleed
diabetes- poor autonomic response
beta blockers
young people compensate well but crash hard if below 1.5 litres of blood (average in adult is 5 litres circulating)
what is an OGD
oesophageal gasto duodenoscopy
what is the uses of the OGD
identify cause, therapeutic manoeuvres, asses risk of rebleeding
what co morbiditys increase the rockall risk scoring system
2:
IHD, CCF,
3:
renal or liver failure, malignancy
what are features of a high risk ulcers/ the stigmata of recent haemorrhage
active bleeding/oozing, overlying clot, visible vessel
what does the blatchford score assess
risk of GI bleed- a score of 0-1 means patient can be discharged with arrangement for later endoscopy
what are the treatments for a bleeding peptic ulcer
endoscopic treatment (high risk ulcers) acid suppression (infusions omeprazole) intervention radiology surgery H. pylori eradication (secondary prevention)
what is involved in the endoscopic treatment of peptis ulcers
injection heater probe coagulation combinations clips haemospray
how does an endoscopic injection work to stop a peptic ulcer bleeding
as injection of adrenaline shifts the thrombotic- fibrinolytic (acid and pepsin in lumen) balance towards clot formation (fibrinolysins in blood vessel)
what is endoscopic dual therapy
injection + heater probe/ clip
how dilated is the adrenaline in an endoscopic injection
1:10000
where are the endoscopic clips placed
on vessels one either side of ulcer
what is hemospray
When Hemospray comes in contact with blood, the powder absorbs water, then acts both cohesively and adhesively, forming a mechanical barrier over the bleeding site.
what is the purpose of acid suppression and what is used to do this
prevents re bleeding- IV omeprazole
what is the treatment pathway of a successfully treated peptic ulcer
PEPTIC ULCER AT ENDOSCOPY
(bleeding or with stigmata of recent haemorrhage)
adrenaline injection/heater probe thermo-coagulation/clips
bleed stops
omeprazole 80mg iv
+
8mg/hr/72hrs ivi
H. pylori eradication
as appropriate and
course of oral PPI
what should yuo do if there is a re-bleld of a peptic ulcer after dual therapy
omeprazole 80mg iv
+
8mg/hr/72hrs ivi
Further attempt at
endoscopic therapy
(if bleed continues)
surgery
what is a ppi and give exmaple
proton pump inhibitor, acid suppressor, omeprazole
what is the main cause of variceal bleeds
liver disease- cirrhosis- portal hypertension
what is the main complication of liver diease
sepsis
what is childs score
measure of severity of liver disease, A, B, C- C most severe
what are the risk factors for a variceal bleed
- portal pressure > 12mmHg
- varices > 25% oesophageal lumen
- presence of red signs (mucosal weakening)
- degree of liver failure (Child’s A<b></b>
why is the mortality of variceal bleeds so high (25-50%)
due to complications - sepsis, liver failure
what is the anatomy of varises
As cirrhosis advanced resistance to portal vein increases which increases portal pressure
Blood tries to find other way back than through the liver- drain upwards through the parioesophageal venous plexus to try and get back to azygous vein, vessels distend and causes oeshophageal varisces
what would make you suspect varices in a patient with a GI bleed
known history of cirrhosis with varices history; -chronic alcohol excess -chronic viral hepatitis infection -metabolic/ autoimmune liver disease -intra-abdominal sepsis/surgery
on examination:
-stigmata of chronic liver disease
what are the stigmata of chronic liver disease
spider naevi, palmar erythema, encephalopathy (nuerotoxic effect on the brain, liver flap, drowsy, inability to copy 5 sided star), ascites, jaundice, leukonychia
what are the aims of management of a variceal GI bleed
Resusciation Haemostasis Prevent complications of bleeding Prevent deterioration of liver function Prevent early re-bleeding
what ions might need to be replaced in a GI bleed
K+, MG2+ and (PO4)2-
how is haemostasis
Terlipressin (vasopressin analogue- constricts blood supply to the gut so reduces portal pressure)
Endoscopic variceal ligation (banding)
(Sclerotherapy)
Sengstaken-Blakemore balloon
TIPS- decompresses portal venous system
what is terlipressin
vasopressin pro drug- splanchnic vasoconstrictors, beneficial effect of renal perfusion
when should a sengstaken- blakemore tube be used
as a delay until endoscope
what is TIPS
blood shortcuts liver and goes straight to systemic venous system reducing portal pressure
why is propanolol used in a variceal bleed
to reduce portal blood pressure
why is banding used in variceal bleeds
is a further procedure to completely get rid of varices
