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MBBS IV - Junior Clerkship WCS > JC52 (Surgery) - Upper GI Bleed > Flashcards

JC52 (Surgery) - Upper GI Bleed Flashcards

1
Q

Common causes of UGIB

A

Peptic ulcer disease (most common)

Gastro-esophageal varices

Esophagitis, Gastritis or duodenitis

Gastric malignancies

Mallory-Weiss syndrome

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2
Q

Rarer causes of UGIB

A

Oesophageal tumour

Stomach
Portal hypertensive gastropathy, GAVE, Dieulafoy’s lesion

Small bowels
Aortoduodenal fistula, angiodysplasia, GI stromal tumour (GIST), diverticular bleeding, Crohn’s disease

Biliary tree
Haemobilia, haemosuccus pancreaticus

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3
Q

Variceal hemorrhage

  • Bleeding pattern
  • Cause
  • Relevant history
A

Bleeding pattern:
Large volume haematemesis/melena ± haematochezia (seldom coffee ground)

Cause: Liver cirrhosis, Portal hypertension leading to collateral vein distension

Relevant history:
 Chronic hepatitis carrier status
 Hx of cirrhosis and chronic liver disease
 Hx of oesophageal varices with banding

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4
Q

Esophagitis causing UGIB

  • Bleeding pattern
  • Cause
  • Relevant history
A

Bleeding pattern: Usually haematemesis only

Causes: Reflux, Radiation, Infection, drugs, scleroderma…etc

Relevant history:
 Reflux: obesity, middle aged, Hx of heartburn, acid regurgitation, acid/water brash
 Irradiation: Hx of H&N and thoracic malignancy
 Infectious: usually in immunocompromised patients (Candida, HSV, CMV)
 Drug-induced: NSAID, tetracyclines, alendronate, Potassium Chloride
 Sclerotherapy-induced: Hx of endoscopic intervention

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5
Q

Mallory-Weiss tears

  • Bleeding pattern
  • Cause
  • Relevant history
A

Bleeding pattern: small volume bleeding

Cause:
Longitudinal mucosal lacerations in distal oesophagus and proximal stomach
caused by violent retching

Relevant history:
Hx of repeated vomiting and its predisposing factors (alcoholism, chemotherapy)
Hx of sudden ↑intra-abd pressure¸ eg. straining, seizures, blunt abd injury

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6
Q

Gastritis or Duodenitis

  • Bleeding pattern
  • Cause
  • Relevant history
A

Bleeding pattern: minor bleeding, self-limiting

Causes: Drugs, alcohol, stress

Relevant history:
Drug induced due to local (GI) and systemic effect (blood) of aspirin and NSAIDs
Alcohol-induced: Acute (esp after binge drinking) or chronic
Stress gastritis: ICU patients with resp failure, hypotension, sepsis, renal failure, burns

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7
Q

Dieulafoy’s lesion

  • Bleeding pattern
  • Cause
  • Relevant history
A

Bleeding pattern: Often self-limiting bleeding but can be recurrent and profuse

Cause:
Vascular malformation with idiopathic dilated aberrant submucosal vessels eroding overlying normal mucosa, at gastric fundus

Relevant finding:
Pool of blood in stomach w/o any localizing lesion
UGIB without localization

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8
Q

Portal HTN gastropathy

  • Bleeding pattern
  • Cause
  • Relevant history
A

Bleeding pattern: Rarely bleeds, only in severe/ late presentation

Cause: Liver Cirrhosis

Relevant history:
Endoscopy incidental finding: gastric mucosa with mosaic, snakeskin appearance
Hx of liver cirrhosis

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9
Q

Gastric antral vascular ectasia (GAVE)

  • Bleeding pattern
  • Cause
  • Relevant history
A

Bleeding pattern:
Melena or haematochezia, not acute profuse bleeding

Cause:

  • dilated antral small blood vessels of unknown cause
  • giving rise to erythematous bands with watermelon appearance on endoscopy

Relevant history:
History of cirrhosis, Scleroderma, CKD,

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10
Q

List upper GI malignancies that can cause UGIB

Bleeding pattern
Relevant history

A

Examples:
CA oesophagus, adenoCA of stomach, GIST, lymphoma, duodenal CA

Bleeding pattern:
self-limiting bleed but can be severe

Relevant history:
 Hx of dysphagia (CA oesophagus/cardia)
 Hx of ulcer-like discomfort, early satiety, bloating (CA stomach)
 Constitutional S/S, eg. loss of weight, loss of appetite

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11
Q

Peptic ulcer disease

  • Bleeding pattern
  • Ulcer sites
  • Relevant history
A

Bleeding pattern: Variable bleeding ± prior epigastric pain

Sites: duodenal, gastric, oesophageal, stomal (eg. jejunal side of gastrojejunostomy)
Ulcers high on lesser curve and in postero-inferior wall of D1 bleed more easily

Relevant history:
 Hx of dyspepsia
 Hx of H. pylori infection: urea breath test, OGD, triple therapy
 DHx of NSAIDs, antiplatelets, steroids, anticoagulants, TCM
 Recent Hx of stress, eg. burns (Curling ulcer), ↑ICP (Cushing’s ulcer)

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12
Q

Angiodysplasia-caused UGIB

  • Bleeding pattern
  • Cause
  • Site
  • Relevant history
A

Bleeding pattern: Variable

Cause: vascular malformation

Sites: usually in colon, can occur in stomach and duodenum

Relevant history:
 Advanced age
 Hx of aortic valve disease
 Hx of chronic renal failure
 Hx of hereditary haemorrhagic telangiectasia
 Hx of prior RT
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13
Q

Aortoenteric fistula

  • Bleeding pattern
  • Cause
  • Site
  • Relevant history
A

Bleeding pattern: Life-threatening, severe bleed

Cause: erosion of AAA into GI tract, after graft repair as graft infection erode into duodenum and create fistula between duodenum and aorta

Site: D3/4 (aorta just behind)

Relevant history:
 Hx of endovascular Tx or aortic surgery
 Hx of AAA

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14
Q

Differentiate acute vs chronic UGIB presentation

A

Acute:

  • Haematemesis
  • Coffee ground vomiting
  • Fresh blood or coffee ground vomit from NG tube
  • Fresh PR bleeding/ Haematochezia
  • Melaena

Chronic bleed:
- Small amount: asymptomatic iron deficiency anaemia, fecal occult blood test positive

  • Moderate amount: symptomatic anaemia, melena
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15
Q

Differentiate ongoing/ severe UGIB vs Slow/ stopped UGIB

A

Ongoing/ severe:

  • Hematemesis
  • Fresh melena

Slow/ stopped:

  • Coffee ground vomit
  • Stale melena
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16
Q

Coffee ground vomitus

  • Cause of appearance
  • Associated diseases
  • Bleeding severity
A
  • Cause: UGI blood oxidized by gastric acid → vomitus containing methaemoglobin
  • Associated diseases: gastric ulcers, gastritis, small amounts of variceal blood
  • Bleeding severity: mild bleeding from stomach or beyond
17
Q

Haematemesis

  • Cause of appearance
  • Associated diseases
  • Bleeding severity
A
  • Cause: vomiting of fresh, unaltered blood → increase time spent in stomach → oxidization → red colour turns brown gradually
  • Associated diseases: variceal bleeding, Mallory-Weiss tears, AV malformation
  • Bleeding severity: Indicates: moderate-to-severe bleeding or from a source proximal to stomach
18
Q

Melena

  • Distinguish fresh vs stale melena
  • Cause of appearance
  • Important Ddx
  • Bleeding severity
A

Fresh melaena = haematin + Hb; jet black with tarry non-particulate liquid stools
→ indicates acute ongoing bleeding

Old (stale) melaena = haematin only; black-grey, dull and mixed with normal stools
→ indicates bleeding has stopped

Cause: blood in GI tract digested by gut bacteria enzymes → black haematin in stools → hematin is a cathartic substance that induces diarrhea

Ddx: 
iron stools from iron supplements, differences:
- More likely to be constipated 
- solid, green/black stools
- Not pungent smell like melena

Bleeding severity:
indicates LGIB unless very profuse UGIB

19
Q

Outline history taking for UGIB

A
  1. Ascertain true UGIB: rule out hemoptysis, upper airway bleed
  2. Assess urgency and resuscitation: S/S of hypovolemic shock, anaemia S/S
  3. Characterize bleed
    - Nature, number of times, amount, duration
    - Bleeding history
  4. Screen for underlying causes:
    - Variceal bleed, Peptic ulcer bleed …etc
  5. S/S of malignancies
    - Constitutional symptoms
    - Early satiety, dysphagia
    - Signs of metastasis: liver, lungs…etc
    - Family history
  6. Associated symptoms, precipitating factors:
    - Bleeding tendencies
    - Alcohol use
    - Caustic substance ingestion
    - DRUGS
20
Q

Questions to screen for variceal bleeding in history taking

A

□ Hx and S/S of liver disease: ascites, jaundice, hepatic encephalopathy (these pt can still have ulcers)
□ RFs of chronic liver disease: hepatitis carrier status, alcoholism, FHx of HCC/hepatitis
□ Hx of previous variceal bleeding: any previous UGIB, OGD, banding

21
Q

Questions to screen for peptic ulcer bleeding in history taking

A

Previous dyspepsia/meal-related pain: ↑with eating (gastric) vs ↓with eating (duodenal)

Hx of peptic ulcer ± bleeding: ulcer recurrence

Hx of H. pylori testing, treatment and F/U:
→ could be Hp-negative peptic ulcers (eg. drug-induced)

Recent use of NSAIDs and TCM (some TCM may contain NSAIDs)

Recent severe metabolic stress, eg. burns, ↑ICP

22
Q

Ddx the following associated symptoms with UGIB

□ Dysphagia
□ Vomiting
□ Heartburn, acid regurgitation
□ Early satiety
□ Epigastric pain
A

□ Dysphagia: painful (oesophagitis, ulcers), painless (malignancy)

□ Vomiting: eg. repeatedly, a/w alcohol → Mallor-Weiss tears

□ Heartburn, acid regurgitation: reflux oesophagitis

□ Early satiety: malignancy, peptic ulcer

□ Epigastric pain: peptic ulcer, gastritis, malignancy

23
Q

Drug history for UGIB

Give rationale behind each drug

A

Aspirin - Transient gastritis, antiplatelet

NSAIDs - peptic ulcer

Anticoagulant and antiplatelets

Cardiac drugs - beta blocker - Slow HR may mask effect of hypovolemia, suppress reflex tachycardia

Iron - Black stool mimic melena

24
Q

Outline physical exam for UGIB

A
  1. Confirm bleed:
    - Examine vomitus/ NG tube
    - Perform PR exam for melena
  2. General exam to r/o hypovolemia and anaemia
    - BP, HR, hydration status, pallor…etc
  3. Malignancy
    - Cervical LN
    - Abdominal masses/ organomegaly
  4. Liver cirrhosis and PHTN
    - Caput medusae, splenomegaly, shifting dullness, peritoneal signs
  5. Hereditary vascular anomalies
    - e.g. Telecgiectasiae in HHT
  6. Occult bleed in nose/ mouth
25
Q

First-line investigations and rationale for UGIB

A

CBC: Hb, MCV, Platelet, Haemocue

LFT: liver diseases, Ammonia for cirrhosis

RFT: electrolytes and Urea/Creatinine
- U/C ratio >100:1 indicates breakdown of GI blood and hypovolemia

Clotting profile: bleeding tendencies

T/S, cross-match for transfusion

Erect CXR for aspiration pneumonia and perforations

NGT suction if uncertain bleeding source

26
Q

Resuscitation methods for severe UGIB

A

Secure hypovolemic shock:

  • ABC
  • Nil by mouth +/- NG tube for decompression
  • Large bore IV cannula (rapid fluid resuscitation)
  • Group O Rh-ve blood with colloids for immediate transfusion
  • T/S and cross-match + Haemocue + Basic blood panels
  • Erect CXR for perforation and pneumonia

Stop bleeding:

  • Medication: PPI, prokinetics, Vasoactive drugs
  • Immediate OGD
  • Balloon tamponade for uncontrollable variceal bleed
27
Q

Monitoring of resuscitation after severe UGIB

A

Monitoring by:
□ Shock chart hourly
□ Vitals: BP/P, RR, body temp
□ Foley’s catheter: IV fluid to aim urine output ≥0.5mL/kg/h
□ Cardiac monitor, pulse oximetry
□ ± CVP line for PAWP (pulmonary arterial wedge pressure)

28
Q

Medication before OGD to investigate UGIB

A

IV PPI

IV prokinetics (eg. erythromycin, metoclopramide): ↑gastric emptying → improve gastric visualization in OGD

Reversal of coagulopathy if any (eg. stopping aspirin, vitamin K + PCC for warfarin)

29
Q

Immediate medical treatment of variceal bleeding

A

Vasoactive medications (eg. somatostatin, terlipressin) → ↓portal pressure → ↓bleeding

Abx prophylaxis (IV augmentin, IV levofloxacin) → ↓2o infection

Consider lactulose for HE

30
Q

Methods to locate source of UGIB

A

□ Upper endoscopy (first-line)

□ Colonoscopy for LGI sources

□ ± capsule endoscopy, double/single balloon enteroscopy for small bowel sources

□ ± RBC scan, angiography for occult bleeding

31
Q

Name of classification for peptic ulcer and re-bleeding chance

Function of classification?

A

Forrest’s classification (endoscopic stigmata of recent haemorrhage, ESRH)

Role:

  • stratify endoscopic finding in bleeding peptic ulcers
  • estimate chance of rebleeding
  • guide whether endoscopic Tx is required
32
Q

Outline the Forrest’s classification for Peptic ulcer bleeds

A
33
Q

Endoscopic modalities of UGIB treatment

A

Endoscopic Tx modalities: usually dual therapy (adrenaline + another modality)

  1. Adrenaline injection: volume effect, induce vasoconstriction, attract platelet for thrombosis
  2. Thermal cauterization (with risk of perforation)
    - Heat probes
    - Laser coagulation
    - Argon plasma coagulation
  3. Mechanical (haemoclip) for large visible vessels, colonic diverticular bleeding and temporary control in Mallory-Weiss tears
  4. Haemospray: Nanopowder to induce haemostasis
  5. Band ligation/sclerotherapy: for varices
34
Q

Complications of Endoscopic treatment of UGIB

A

□ Anaesthetic risk: respiratory depression, MI, CVA

□ Procedure-related: aspiration, bleeding, perforation, failure of haemostasis, failure of complete scope (to D2)

35
Q

Monitoring after endoscopic treatment of UGIB

A

Close monitoring for rebleeding

  • Inpatient care for 3 days
  • Check S/S of rebleeding: ↑pulse rate, haematemesis, fresh blood from NGT, fresh melaena, sudden ↓Hb
  • Second-look endoscopy if suspicious of recurrent bleed
36
Q

Risk factors for recurrent UGIB

  • Severity at presentation
  • Patient factors
  • Location of bleed
A

Presentation:

  • Shock at presentation
  • Hb <8.0g/dL at presentation
  • Require Transfusion

Patient factors:

  • Age >60
  • Multiple comorbidities
  • Coagulopathy with medication

Location of bleed:

  • Large ulcer on posterior D1 > Close to gastroduodenal artery
  • Large ulcer on high posterior lesser curvature > Close to left gastric artery
37
Q

Open surgery for UGIB

  • Indications
  • Methods (3)
A

Indications: usually for ulcers

  • Endoscopy failed/ not available
  • Massive bleeding with significant haemodynamic instability
  • Associated perforations

Methods:

  • Plication and closure of duodenal ulcer + Truncal Vagotomy + Pyloroplasty (after vagotomy to stop pylorus spasm)
  • Plication with biopsy of gastric ulcer (malignant potential)
  • Gastric ulcer resection: ulcerectomy, partial gastrectomy ± reconstruction (usu Billroth I or II)

MBBS IV - Junior Clerkship WCS (131 decks)

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