Gl Bleeding Flashcards
What is the Ligament of Treitz?
An anatomical structure separating the upper GI and lower GI.
What are the components of the upper GI tract?
- Oesophagus
- Stomach
- Upper duodenum
What is the most common cause of upper GI bleeding?
NSAIDs block COX-1 pathway that reduces prostaglandin synthesis which stimulates gastric mucus and bicarbonate secretion or gastrinoma.
What is Haematemesis?
Vomiting blood.
What is melena?
Black sticky and tarry appearing stools.
Why is upper GI bleeding typically darker?
Because blood is oxidised by the HCL.
What are common causes of upper GI bleeds?
- Gastric ulcers
- Duodenal ulcers
- Oesophageal varices
What is the cause of oesophageal varices?
Oesophageal varices typically occur due tp portal hypertension causing backflow and resulting in variceal bleeding. This is associated with liver cirrhosis, but can occur with severe right sided heart failure, constrictive pericarditis, Budd-Chiari syndrome and a massive splenomegaly. The portal venous system has no valves so increased resistance with the right side of the heart, liver causes retrograde flow and tortuous dilated veins. A major risk factor is active alcohol consumption.
What is the clinical presentation of oesophageal varices?
Haematemesis, melena or haematochezia, jaundice, anorexia, splenomegaly. The peripheral stigmata of alcohol abuse may be present. Thrombocytopenia, anaemia and elevated ALT, BUN and AST are indicators. Hepatic vein pressure gradient is the gold standard for diagnosis it clinically signficant portal hypertension
What is the peripheral stigmata of alcohol abuse?
The peripheral stigmata of alcohol abuse may be present, which is palmar erythema, gynaecomastia, testicular atrophy and spider angiomata.
What condition typically causes oesophageal varices?
Portal hypertension.
What is a major risk factor for oesophageal varices?
Active alcohol consumption.
What clinical presentations are associated with oesophageal varices?
- Haematemesis
- Melena
- Jaundice
- Anorexia
- Splenomegaly
What is the clinical presentation of oesophageal cancer?
Patients present with progressive dysphagia, affecting solids and liquids as tumour enlarges, with unintentional weight loss and odynophagia (painful swallowing). Chest pain may develop and hoarseness of voice cervical and supraclavicular Lymphadenopathy can indicate metastatic spread.
What is the common site of metastasis?
Frequent sites of metastasis are the liver, lungs and lymph nodes and peritoneum.
What is treatment of oesophageal cancer?
Treatment is endoscopic resection or ablation for superficial disease. For lymph node involvement, resection of oesophagus and lymph nodes or chemo radiation.
What is a Mallory Weiss tear?
A longitudinal tear in the oesophageal wall associated with vomiting/retching.
How does Mallory Weiss syndrome present?/
Patients are typically asymptomatic apart from Haematemesis which can be blood streaked mucus to massive bright red blood volumes. With severe bleeding, melena, dizziness and syncope may occur. In the presence of GERD, epigastric pain may be present.
How is Mallory Weiss syndrome treated?
It is treated with PPI inhibitor, H2 blockers to decrease gastric acidity. They may gave dilated tortuous vessels around the lower oesophagus, which is a complication of portal hypertension.
What is the cause of gastritis?
NSAIDs, alcohol, Cushing’s ulcers or H.pylori infection
What is peptic ulcer disease commonly associated with?
- H.pylori infection
- Use of NSAIDs
How is helicobacter pylori infection transmitted?
H.pylori infection which is transmitted via direct contact with saliva, vomit or stool, through contaimined food or water. It produces bacterial urease that counteracts the effects of gastric acid and the toxins released cause damage to the mucosa lining
What does H.pylori infection produce that counteracts gastric acid?
Bacterial urease.
What are the protective factors for oesophageal adenocarcionoma?
Protective factors are fruit and veg intake, PPIs, NSAIDs and high fibres diet. Treatment is typically with resection.
What is Dieulafoy’s lesion?
A shallow large tortuous mucosal artery that causes intermittent bleeding. It is a vascular malformation where the diameter of the blood vessel is abrnoamlly wide and can cause surrounding fibrinoid necrosis, typically affecting the stomach. It is associated with CKD, hypertension, diabetes and cardiovascula disease. Patients are typically asymptomatic unless the lesion affects the gall bladder, then there is upper abdominal pain.
What is the treatment of Dieulafoy’s lesion?
Treatment is typically endoscopy with thermal, heat or plasma coagulation with adrenaline injection and mechanical banding and haemoclips. There is a risk of spontaneous massive haemorrhag if left treated. Risk factors include NSAIDs and alcohol.
What is the most common type of oesophageal cancer?
Oesophageal cancer is divided into squamous cell carcinoma and adenocarcinoma.
What is the cause of Squamous oesophageal cancer?
There is chronic inflammation and carcinogen exposure resulting in dysplasitc changes to epithelia which is associated with smoking, alcohol consumption, and a diet low in fruits and vegetables an drinking hot beverages/ conditions like HPV infection and Fanconi anaemia may increase the risk. Alcohol increases risk due to increasing the permeability of the mucosa to carcinogen absorption
What is the cause of oesophageal adenocarcionoma?
Oesophageal adenocarcinoma arises from repeated exposure of the lower oesophagus to stomach acid from Barrett metaplasia, resulting in columnar epithelia replacing normal squamous epithelium. Risk factors including smoking, high body mass index, gastroesophageal reflux disease (GERD), and a diet low in fruits and vegetables. There is no association with alcohol intake. Protective factors are fruit and veg intake, PPIs, NSAIDs and high fibres diet. Treatment is typically with resection.
What are risk factors for oesophageal adenocarcinoma?
- Smoking
- High body mass index
- GERD
- Diet low in fruits and vegetables
Which medication cause upper GI bleed?
NSAIDs
Corticosteroids impair tissue repair and delays wound healing
SSRIs inhibit uptake and steroage of serotonin by platelets, reducing their function and predisposing to bleeding
Antiplatelet drugs
What is Barrett metaplasia?
Replacement of normal squamous epithelium with columnar epithelium due to acid exposure.
What are common symptoms of oesophageal cancer?
- Progressive dysphagia
- Unintentional weight loss
- Odynophagia
- Chest pain
- Hoarseness of voice
What is the Macklemore triad associated with Boerhaave syndrome?
- Vomiting
- Chest pain
- Subcutaneous emphysema
How do patients present with Boerhaave syndrome?
Patients may present with hoarseness of voice, dysphagia, respiratory distress and vomiting. Imaging will show subcutaneous or mediastinal emphysema, widening and pleural effusion.
How does Boerhaave syndrome managed?
Management is avoiding all oral intake, parenterally nutrition and broad spectrum IV antibiotics
What are the risk factors for Boerhaave syndrome?
Risk factors for Boerhaave syndrome are alcoholic dependence and food overindulgence, weightlifting, defaecation, epileptic seizures, an ordinal trauma or child birth.
What are the complications of GERD?
- Strictures
- Barrett’s oesophagus
How does oesophageal rupture present?
Oesophageal rupture can result in sudden retrosternal chest pain, along with respiratory distress, severe vomiting/retching and subcutaneous emphysema. On examination, patient will have dullness to percussion, reduced air entry and oelural effusion.
How is oesophageal rupture managed?
There is a high risk of sepsis and low BP regulation, so acute management is fluid resuscitation with high flow oxygen, broad spectrum antibiotics and antifungals. Definitive management is removal of contamination in the mediastinum, Decompression of the oesophagus and nutritional support
What can precipitate oesophageal rupture?
This can occur due to a period of severe vomiting, surgical procedures, spontaneous rupture or choking on a piece of food.
What should occur prior to treatment for oesophageal rupture?
Non-operative treatment may mean nil-by-mouth with a chest drain insertion and parenterally nutrition, antibiotic and antifungal drugs and endoscopic therapy. It has a high morbidity and mortality rate.
What is the primary treatment for upper GI bleeding?
Endoscopic intervention.
What is the gold standard for diagnosing clinically significant portal hypertension?
Hepatic vein pressure gradient.
What medications can cause upper GI bleeding aside from NSAIDs?
- Corticosteroids
- SSRIs
- Antiplatelet drugs
Why do duodenal ulcers occur?
Duodenal ulcers occur typically as part of peptic ulcer disease, where there is disruption to the mucosal surface, associated with dyspepsia (indigestion). It occurs due to either heavy NSAIDs use or diagnosis of H.pylori which weakens the mucosal surfaces to gastric acid secretion.They most commonly occur in those aged 20 to 45 and more common in men.
How do duodenal ulcers present?
Patients commonly present with dyspepsia, melena, Haematemesis, elevated BUN and anaemia with fatigue.
How does duodenal ulcers present On examination?
On examination, patinets may have epigastric abdominal tenderness and signs of anaemia like pale skin and positive foecal ooccult blood test
What are the complications of upper GI bleeding?
Complication of upper GI bleeding includes syncope, shock infection, death, myocardial infarction and respiratory distress
What are the classifications of lower GI?
It is classified into massive, moderate and occult bleeding.
There is typically loss of haemoglobin and results in anaemia and drop in blood volume and blood pressure, causing hypotension and risk of hypovolemic/haemorrhagic shock.
What is the cause of massive bleeding in over 65’s?
Massive bleeding is in patients older than 65 with multi-morbidity, haematochezia and haemodynamically stable.
What is the most common cause of lower GI bleeding in under 50s?
Most common cause of lower GI bleeds in under 50s are haemorrhoids, with external haemorrhoids below pectinate line and more painful than internal haemorrhoids
What is the typical presentation of anal fissures?
Anal pain worse with defaecation and blood with defaecation.
What are the characteristics of internal haemorrhoids?
Painless bleeding, bright red on wiping, cannot be palpated on digital rectal exam. internal haemorrhoids arise from the arterial plexus and occur above pectinate line
What are the characteristics of external haemorrhoids?
Presentation is feeling of fullness and itching and discomfort in anus worsened by sitting for long periods, discharge of mucus and blood on surface of the stool. external haemorrhoids arise from the arterial plexus occur below pectinate line.
What are the features of arteriovenous malformation?
Arteriovenous malformation typically in the ascending colon due to aortic stenosis or chronic kidney disease
What is diverticulosis?
Pouches in the intestinal lining that become inflamed, causing abdominal pain and bloating.
What is the scoring system for GI Bleeding used for?
Rockall score determine the severity of a GI bleed and risk of rebleeding and mortality.
What is the difference between active and non-active lower GI bleeding?
- Active: spontaneous passing of red or brown blood from the rectum
- Non-active: marrow or black stool.
What are common causes of rectal bleeding?
- Anal fissure
- Haemorrhoids
- IBD
- Colorectal cancer
What is occult bleeding?
Occult bleeding occurs at any age, with blood not obvious unless tested and there is microycytic hypochromic anaemia due to chronic blood loss, typically due to a cancer, inflammatory disease or congenital. Patient appears well and stable
Where is IBD bleeding present?
IBD, typically more ulcerative colitis in the descending colon with haematochezia, lower left quadrant pain and tenesmus
What is the typical presentation of a patient with a duodenal ulcer?
- Dyspepsia
- Melena
- Haematemesis
- Elevated BUN
- Anaemia
What is a risk with lower GI bleeds?
Lower GI bleeds have a risk of ischaemic colitis due to reduced mesenteric flow to the colon.
Which areas of the colon are at risk of ischaemic colitis?
The splenic flexure is the watershed area which is most at risk, located between the area that the superior and inferior mesenteric artery. Rectosigmoid junction is another region, between the inferior mesenteric artery supply and superior rectal artery.
How does left colon blood present?
bright red
How do right colon bleeds present?
clots with melena except for brisk and massive bleeds
What is aortoenteric fistula?
A rare but fatal complication associated with recent aortic surgery.
What is the risk factor for ischaemic colitis?
Reduced mesenteric flow to the colon.
What is the features of the Rockall score?
severity of GI bleeding in and risk of re-bleeding based on:
*age over 60
*signs of shock like tachycardia and hypotension
*co-morbidities like liver or rena disease or malignancy
* the major stigmata of recent bleed.
What is the stigmata of recent bleed?
The stigmata of recent bleed is visible or spurting vessel, adherent clot and blood in GI tract
What are the general tests for GI bleed?
abdominal examination
FBC for MCV and BUN ratio and coagulation panel
Stool occult test
What scoring system is sed to determine high risk patients with lower GI bleeding?
BLEED criteria
Bleeding
Low systolic BP
Elevated PT time of extrinsic pathway
Erratic mental state
Disease process that warrants ICU admission, even in absence of bleed
What score indicates a high rebleeding rate in patients?
A score of 6 or more indicates a high rebleeding rate in Rockall
The scoring system assesses the risk of rebleeding in patients with upper GI bleeding.
What are common causes of rectal bleeding
Anal tissue
Constipation
Haemorrhoids
IBD
Colorectal cancer
Proctitis
Divertiuclosis
What is proctitis?
Proctitis is inflammation of the rectum presenting with rectal pain, diarrhoea, bright red blood and mucus discharge and tenesmus
What is the risk for anal fissure?
Anal fissure is a superficial tear in the skin below the pectinate line, which is common in those that have a history of constipation. It is caused by constipation, sexual intercouse, childbearing, STD’s and cancer. Presentation is anal pain worse with defaecation and this persists for hours after defaecation and blood with defaecation.
How is an upper GI bleed managed?
Blood transfusion for haemodynamically unstable patients. If they remain unstable, angiogram is important to locate bleeding and an IR coil to embolise the bleeding, and this is ideal for arteriovenous malformation or surgery to find the bleeeding
What is the gold standard for assessing and cauterising bleeding in haemodynamically stable patients?
Endogastric tube evaluation
This procedure allows for direct evaluation and treatment of the bleeding site.
What is a sign with peritonitis on examination?
Blumberg’s sign is pain upon removal of pressure to abdomen
What causes elevated BUN ratio?
upper GI bleed because of digestion of blood in the digestive system
How to test for h.pylori infection?
PCR test from a stool sample and a urea breath test
How should oesophageal varices be treated?
With banding Ligation that is used to cut off blood supply and will develop into an ulceration that will heal there is risk of scarring of oesophagus and further bleeding. Beta blocker can be given to reduce load pressure in the portal vein.
and prophylactic antibiotic therapy. Terlipressin should be offered.
Terlipressin is also recommended as a vasopressin receptor agonist.
What is Terlipressin?
vasopressin receptor agonist that only causes vasoconstriction in the splanchnic circulation, but otherwise is a vasoconstrictor systemically. used in pesp[jagea varices
What is recommended for gastric varices in upper GI bleeding?
N-butyl-2-cyanoacrylate and transjugular intrahepatic portosystemic shunt (TIPS) to relive pressure
These treatments relieve pressure in gastric varices.
What is the scoring system for likelihood of upper GI bleed requiring intervention?
glasgow-blatchford score used To assess the likelihood of needing endoscopy or blood transfusion in upper GI bleeding
It considers factors like haemoglobin, BUN, and blood pressure.
How is a lower GI bleed assessed?
patients should be assessed for shock index to determine stability, based on heart rate/ systolic blood pressure. Shock index over 1 indicates active bleeding, index less than one can be classiied as a stable lower GI bleed
What scoring system classifieds GI bleeds?
Oakland score based on age over 70, make, previous LGIB admission, DRE found blood, systolic BP over 90 and haemoglobin over 70.
How should major risk patients be managed?
admtted for colonoscopy further investigations like capsule endoscopy, CT angiogram
How should unstable patinets with GI bleed be imaged?
CT angiogram
What is the imaging for lower GI bleeding ?
Colonoscopy for Lower GI bleed suspected
For intermittent bleeding, tagged RBC scan or CT angiogram which is better for localising bleeding location when endoscopy fails to identify active bleeding
Push enteroscopy can be used for assessing jejunum and ileum
Capsule endoscopy with swallowing pill, ideal for stable patients
What is the shock index used for in assessing lower GI bleeding?
To determine stability based on heart rate and systolic blood pressure
A shock index over 1 indicates active bleeding.
What should be done if a colonoscopy for lower GI bleeding is normal?
Further investigations like capsule endoscopy or CT angiogram should be arranged
This helps identify the source of bleeding if not found during colonoscopy.
When is band ligation indicated?
dieulafoy lesion
Oesophageal varices
What is the initial management for GI bleed?
Early intensive Resuscitation with packed RBCs is indicated for patients with haemoglobin less than 7g/dL to replace blood lost to keep Haemoglobin above 7 but for those with myocardial ischaemia, resuscitation with transfusion should Elgin where haemoglobin is below 8g.dL
What is the initial treatment of upper GI bleed?
IV PPI To stabilize clot formation and promote mucosal healing
PPIs help reduce gastric acid secretion.
Which pharmacotherapy is indicated for oesophageal varices?
ocreotide, a somatostatin analogue that causes vasoconstriction the portal varices to reduce portal pressure.
What should be considered for patinets with liver cirrhosis in treatment?
antibiotic prophylaxis with cephalosporin cetriaxone fo2 to 5 days because of risk of bacterial translocation,, aspiration pneumonia and spontaneous bacterial peritonitis, typically with cetriaxone (cephalosporin)
What is alternative to endoscopy in upper GI bleed?
Transcatheter angiography and embolisation is reserved for intermittent refractory bleeding despite endoscopic therapy or where endoscopy is contraindicated. But there are risks of renal failure, bowel infarction, thromboses and dissection.
What should be avoided in patients on long-term anticoagulation therapy?
Stopping aspirin unless in hypovolemic shock or severe hypotension. Only P2Y12 antagonist should be paused for 5 days because of risk of cardiovascular event
Aspirin should be resumed within 3-5 days post-event.
What is the role of adrenaline in the treatment of GI bleeding?
For vasoconstriction of vessels
Adrenaline should not be used as monotherapy and must be combined with other treatments.
What is the recommended treatment for H. pylori infection?
Clarithromycin, metronidazole, and amoxicillin
This combination is effective in eradicating H. pylori.
What is the NICE guideline for patients with upper GI bleeding?
Patients should undergo risk assessment with the Blatchford score prior to intervention
Following endoscopy, the Rockall score is used for further assessment.
What is the purpose of using haemoclips in GI bleeding treatment?
To ligate surrounding tissue and stop bleeding. Oesophago-gastro-duodenoscopy (OGD) is used to assess the lining of the oesophagus, stomach and duodenum and take biopsies and assess for inflammation, using a gastroscope.
Haemoclips are delivered via endoscope.
What are the risks associated with Oesophago-gastro-duodenoscopy (OGD)?
Infection, bleeding, or perforation
These complications can lead to chest or abdominal pain and bloating.
What is the Oakland score used for in lower GI bleeding?
To classify bleeds as major or minor based on specific risk factors
Factors include age, previous admissions, and blood findings.
What should be performed before a colonoscopy?
Digital rectal examination
This helps assess for abnormalities and guide further investigation.
What is the primary treatment for diverticular disease?
Adrenaline injection
This helps with bleeding management in diverticular disease.
What are the symptoms indicating a potential colon cancer?
Rectal bleeding, abdominal pain, and anaemia
Right-sided tumours often present with anaemia, while left-sided cause defecation disturbances.
What patient presentation indicates colorectal cancer?
Patients over age 40 with new onset, persistent or reccurrent rectal bleeding should be referred for investigation and risk assessment with family history abdominal and rectal examination should be performed.
What are the investigations for colorectal cancer?
Faecal immunochemical test
Full blood count to determine cause of anaemia, especially iron deficiency including LFTs and U&Es. Patients with iron deficiency anaemia shold be referred for endoscopy and colonoscopy. Colonoscopy and staging is based on contrast enhanced CT of chest, abdomen and pelvis
MRI and transrectal ultrasound
Biopsy
