JC56 (Medicine) - Upper GI Bleed Flashcards
Anatomical definition of UGIB
Bleeding from source proximal to ligament of Treitz
Define anatomical definition of small bowel bleed
Small bowel bleed
Any bleeding distal to ampulla of Vater and proximal to ileocecal valve
Differentiate overt, occult and obscure GIB
Overt = Passage of visible blood
Occult = Bleeding undetectable by eye, Iron-deficiency anaemia +/- positive fecal occult blood test
Obscure = source of bleeding unknown despite OGD, CLN and SB workup (radiographic, video-capsule endoscopy and enteroscopy)
Differentiate presentation of chronic GIB vs acute GIB
Chronic GIB:
- S/S anaemia: fatigue, palpitations, dyspnea, dizziness, postural hypotension
- Iron deficiency anaemia, FOBT +ve
Acute GIB:
- Hematemesis: fresh blood or coffee-ground vomit
- Fresh blood or coffee ground aspiration from NG tube
- Melena
- Hematochezia/ fresh PR bleed
Melena
- Describe characteristics
- Reason for color
- Associated S/S
- Ddx black stool
Characteristics: Black, tarry stool, loose, sticky, malodorous
Color: Heme oxidized by intestinal bacteria into hematin
S/S: Melena is cathartic >> cause loos stool/ diarrhea
Ddx black stool:
- Iron supplements
- Bismuth
- Activated charcoal
- Food
Define UGIB or LGIB with following presentation
Hematemesis
NG tube with blood
NG tube without blood
Melena
Hematochezia
Hematemesis: UGIB
NG tube with blood: UGIB
NG tube without blood: Usually LGIB or UGIB at duodenum against competent pylorus
Melena: UGIB down to proximal colon
Hematochezia: Usually LGIB, or massive UGIB
Hematochezia with haemodynamic instability may indicate massive UGIB
Immediate assessment and resuscitation for massive UGIB
Assessment of hypovolemia:
- Mild to moderate (<15% loss) - Resting tachycardia
- Loss ≥15% - Orthostatic hypotension
- Loss ≥40% - Supine hypotension
Resuscitation
- ABC
- Large bore IV cannula
- Fluid resuscitation and packed cell transfusion
- Monitor vitals and urine output
Outline associated S/S that help delineate cause of UGIB
Epigastric pain - PU, malignancy
Vomiting after alcohol - Mallory-Weiss tear
Acid reflux - Esophagitis/ ulcer
Painful dysphagia - esophagitis/ ulcer
Painless dysphagia - Variceal bleed
Constitutional symptoms - Malignancy
Drug history for UGIB
Antiplatelets and anticoagulants (e.g. prescribed for stroke, IHD, joint pain..etc)
Rate-lowering drugs - B-blocker (may suppress reflex tachycardia after hypovolemia)
NSAIDs (peptic ulcer)
Prognostic scores for UGIB
Pre-endoscopic ROCKALL score
Glasgow-Blatchford score
Conditions associated with high UGI rebleeding risk
Cirrhosis
Peptic ulcer bleed
Strategies for blood transfusion after UGIB
Indications for each strategy
Restrictive strategy (<7g/dL): better survival, mainstay strat.
Liberal strategy (<9g/dL): For hemodynamically unstable, underlying cardiovascular diseases (ACS)
Measures for UGIB before OGD
- Correct coagulopathy, thrombocytopenia: aim INR <1.5 and platelet count >50
- IV PPI in active PU bleed: Esomeprazole
- Splanchnic vasodilators for cirrhosis variceal bleed: Terlipressin/ Octreotide
- Antibiotics for cirrhosis: 3G cephalosporine or quinolones
- Prokinetics: IV erthromycin/ metoclopramide
Upper endoscopy for UGIB
Key timing for intervention
Hemodynamically stable - within 24h
Hemodynamically unstable/ variceal bleed - within 12h
Ddx UGIB by variceal bleed and non-variceal bleed
Variceal bleed: esophageal or gastric
Non-variceal bleed: esophagus, gastric, duodenum
- Ulcers/ erosions
- Gastritis, duodenitis, esophagitis
- Tumors (GIST)
- Vascular: angiodysplasia/ telangiectasia, Dieulafoy’s lesion’s
- Mallory-Weiss tear
- Portal hypertensive gastropathy
- Anastomotic ulcer
Rare:
- Aortoenteric fistula
- Hemobilia, hemosuccus pancreaticus
- Crohn’s disease
Ulcer UGIB
- Locations
- Major causes
- Classification
Location: Duodenal, gastric, stomal ulcers
Major causes: H. pylori, NSAID/ aspirin, Stress (ICU)
Classification: Forrest Classification
Gastritis/ Duodenitis/ Erosions
- Associated causes
- Helicobacter pylori
- Drug-induced: aspirin and NSAID
aspirin induced transient hemorrhagic gastritis, self-limiting and mild
- Alcohol-induced
- Stress gastritis:
ICU: respiratory failure, hypotension, sepsis, renal failure, burns…etc
Endoscopic gastritis
Esophageal/ gastric varices
Causes
Liver cirrhosis
Non-cirrhotic portal hypertension
Splenic vein thrombosis (isolated gastric varices)
Esophagitis/ Esophageal ulcers
Causes
Acid reflux - obese, middle age, male
Opportunistic Infection: Candida, CMV, Herpes virus in immunocompromised host
Pill-induced: esp. tetracycline, directly lodged and erosion
Sclerotherapy-induced: post-endoscopic intervention
Irradiation
Caustic substance ingestion
Angiodysplasia and UGIB
Typical location
Variants
Associated conditions
Typical location: small bowel and colon
Variants: GAVE - gastric antral vascular ectasia
Associated conditions:
- Elderly
- Cirrhosis
- Chronic renal failure
- Radiation
- Scleroderma
- Hereditary hemorrhagic telangiectasia
- Aortic stenosis (Hedye’s sydnrome)
Treatment modalities for UGIB
Endoscopic:
- Adrenaline injection
- Thermocoagulation - heat probe
- Hemoclips
- Argon plasma coagulation
- Band variceal ligation/ sclerotherapy
- n-butyl-2-cyanoacrylate tissue adhesive
Aspirin should be discontinued for a period after PU bleed
True or false?
False
Early resumption of aspirin does not increase rebleeding risk with PPI coverage
Benefit: Definite reduction in mortality
Second-line investigations for OGD negative patients with severe*** GIB (3 modalities)
Red cell scan
CT angiography
Angiography
Second-line investigations for endoscopy -ve with Severe*** GIB
Compare pros and cons, complications
Red cell scan
- Tc-99m sulfur colloid and tc-99m pertechnetate-labeled autologous RBC
- Sensitive to SLOW or INTERMITTENT bleeds (0.1-0.5mL/min)
- Allow sequential scans to find bleeding site
- Late scan only finds blood pooling, not bleeding site
CT angiography (hemodynamically stable)
- Sensitive to small volume bleed, active bleed (0.3mL/min)
- No therapeutic intervention
- Complications: Contrast allergy, contrast nephropathy
Angiography
- Allows therapeutic intervention
- Only detects high bleeding rates, active bleeding (0.5mL - 1mL/ min), not sensitive to slow/ small volume bleeds
- Complications: catheter site reaction, thromboembolism, contrast allergy
Second-line investigations for endoscopy -ve, subacute** GIB
Compare advantages of each modality
Video capsule endoscopy (VCE) - record small bowel, diagnostic only
- Higher yield for vascular and inflammatory lesions
CT enterography (CTE) - luminal detail, diagnostic only
- Higher yield for small bowel masses
Double-Balloon enteroscopy (DBE) - flexible to prevent stretching of shortened intestine
- Dual approach: Oral antegrade or anal retrograde
- Biopsy and therapeutic intervention possible (e.g. treat bleeding, mucosal neoplastic lesions)
Single balloon enteroscopy (SBE)
Merkel’s scan (last-line to all options)
Indications of video capsule endoscopy
Contraindications
Complications
Indications:
- Obscure GIB
- Non-stricturing small-bowel Crohn’s disease
- Celiac disease
- Hereditary Polyposis syndrome: Peutz- Jeghers syndrome, Familial adenomatous polyposis with duodenal polyps
C/I:
- Known GI obstructions/ strictures
- Swallowing disorders
- Severe motility problems
- Un-cooperative and unreliable
Complications:
- Capsule retention
- Perforation
Compare single vs double balloon enteroscopy
Advantages for each technique
Single balloon:
- 1 operator only (cf 2 for DBE)
- Faster intubation time
- More user friendly
Double balloon: (more prevalent)
- Higher depth of penetration
- Increase holding in ileocecal valve
Merkel’s scan
Function
Limitations
IV Tc-99m pertechnetate adhere to gastric mucosa
Scintigraphy can identify diverticula containing ectopic gastric mucosa
Limitations:
Cannot detect active bleeding
