GI haemorrhage (also see Gen med: acute GI bleed)

Question 1

Name the cardinal features of acute upper GI bleeding

Answer 1

Haematemesis

Melaena

Question 2

What is the commonest cause of Upper GI bleeding?

Answer 2

Peptic ulcers (50%)

Question 3

Name 3 causes of Upper GI bleeding within the oesophagus

Answer 3

Mallory-Weiss syndrome
Oesophageal varices
Oesophageal tumours
Reflux oesophagitis

Question 4

Name 3 causes of Upper GI bleeding within the stomach

Answer 4

Gastric ulcers
Gastritis/gastric erosions
NSAIDs
Gastric carcinoma
Corrosive substances e.g. batteries
Dieulafoy's lesion

Question 5

What is Dieulafoy’s lesion?

Answer 5

Calibre persistent artery - a large tortuous arteriole within the submucosa of the stomach.

Accounts for 1-2% of acute GI bleeding

Question 6

Name 2 causes of Upper GI bleeding within the duodenum

Answer 6

Duodenal ulcers

Haemobilia

Question 7

Name and describe 2 scoring systems used to assess acute Upper GI bleeding

Answer 7

Blatchford score: Determines the need for intervention. Score of 6+ indicates admission.

Rockall score: Predicts the risk of rebleeding and mortality after upper GI bleeding. Initial score of >6 indicates surgical intervention.

Question 8

Outline the management of Upper GI bleeding in a haemodynamically stable patient (3)

Answer 8

Insert 2 large-bore cannulae
Start slow saline IVI
Check bloods, vitals, urine output

Consider transfusion if loss >30% circulating volume

Question 9

Outline the initial medical management of Upper GI bleeding in a shocked patient (10)

Answer 9

Protect airway and keep NBM
Insert 2 large-bore cannulae
Urgent blood Ix, crossmatch 6 units
Rapid fluid resuscitation
Correct clotting abnormalities
Consider referral to ICU, and CVP line
Catheterise and monitor urine output
Monitor vitals every 15min till stable, then hourly
Notify surgeons of severe bleeds
Urgent endoscopy

Question 10

What is the indication for surgical intervention of upper GI bleed?

Answer 10

Failure to control bleed using medical and endoscopic treatment

Rockall score >6

Question 11

How common is acute lower GI bleeding compared to acute upper GI bleeding?

Answer 11

Acute lower GI bleeding is 1/5 as common

Question 12

What are the 2 commonest causes of massive acute lower GI bleeding?

Answer 12

Diverticular disease
Ischaemic colitis
Angiodysplasia

Question 13

Name the 3 causes of small acute lower GI bleeding

Answer 13

Haemorrhoids
Anal fissures
Colorectal cancer
IBD
Vasculitis

Question 14

Outline the management of acute lower GI bleeding

Answer 14

Resuscitation

• 2 large-bore cannulae
• IV fluid/blood resuscitation
• Urinary catheter
• Oxygen

Conservative and radiological treatment

Surgical treatment rarely needed

Question 15

Define angiodysplasia

Answer 15

Vascular malformations of unknown aetiology, most frequently found in the right colon.

Occasionally associated with cutaneous and oral lesions

Question 16

Outline the definitive management of angiodysplasia

Answer 16

Colonoscopic therapy (injection, heater probe, argon plasma coagulation)
Angiographic embolisation
Right hemicolectomy

Question 17

How is lower GI bleeding due to angiodysplasia investigated?

Answer 17

Colonoscopy
Endoscopy
CT angiogram

Seen as cherry red flat lesions

Question 18

Describe the presentation of acute anorectal bleeding

Answer 18

Bright red blood, on the surface of stool and paper, after defecation

Question 19

Name 3 causes of acute anorectal bleeding

Answer 19

Haemorrhoids
Acute anal fissure
Distal proctitis
Rectal prolapse

Question 20

Describe the presentation of acute rectosigmoid bleeding

Answer 20

Darker red blood, with clots, in surface of stool and mixed in stool

Question 21

Name 2 causes of acute rectosigmoid bleeding

Answer 21

Rectal tumours
Proctocolitis
Diverticular disease

Question 22

Describe the presentation of acute proximal colonic bleeding

Answer 22

Dark red blood mixed into stool or altered blood (malaena)

Question 23

Name 3 causes of acute proximal colonic bleeding

Answer 23

Colonic tumours
Colitis
Angiodysplasia
NSAID-induced ulceration

Question 24

What is suggested by acute rectal bleeding and LIF tenderness?

Answer 24

Diverticular inflammation with bleeding

Question 25

What is the definitive management for the majority of anorectal causes of low GI bleeding?

Answer 25

Local measures: injection, coagulation, packing

Question 26

Outline the definitive management for lower GI bleeding due to acute colitis

Answer 26

IV or PO metronidazole if thought to be infective cause - until advice by microbiology
Angiographic embolisation

Directed hemicolectomy if location of bleeding known
Subtotal colectomy (removal of colon, with rectum intact) if location is unknown

Question 27

Name a classification system used to risk stratify upper GI bleeds with ulceration

Answer 27

Forrest classification: used to asses the need for endoscopic intervention in ulcerative upper GI bleeding