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MBBS IV - Junior Clerkship WCS > JC56 (Medicine) - Upper GI Bleed > Flashcards

JC56 (Medicine) - Upper GI Bleed Flashcards

1
Q

Anatomical definition of UGIB

A

Bleeding from source proximal to ligament of Treitz

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2
Q

Define anatomical definition of small bowel bleed

A

Small bowel bleed

Any bleeding distal to ampulla of Vater and proximal to ileocecal valve

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3
Q

Differentiate overt, occult and obscure GIB

A

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)

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4
Q

Differentiate presentation of chronic GIB vs acute GIB

A

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
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5
Q

Melena

  • Describe characteristics
  • Reason for color
  • Associated S/S
  • Ddx black stool
A

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
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6
Q

Define UGIB or LGIB with following presentation

Hematemesis

NG tube with blood

NG tube without blood

Melena

Hematochezia

A

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

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7
Q

Immediate assessment and resuscitation for massive UGIB

A

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
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8
Q

Outline associated S/S that help delineate cause of UGIB

A

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

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9
Q

Drug history for UGIB

A

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)

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10
Q

Prognostic scores for UGIB

A

Pre-endoscopic ROCKALL score

Glasgow-Blatchford score

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11
Q

Conditions associated with high UGI rebleeding risk

A

Cirrhosis

Peptic ulcer bleed

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12
Q

Strategies for blood transfusion after UGIB

Indications for each strategy

A

Restrictive strategy (<7g/dL): better survival, mainstay strat.

Liberal strategy (<9g/dL): For hemodynamically unstable, underlying cardiovascular diseases (ACS)

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13
Q

Measures for UGIB before OGD

A
  1. Correct coagulopathy, thrombocytopenia: aim INR <1.5 and platelet count >50
  2. IV PPI in active PU bleed: Esomeprazole
  3. Splanchnic vasodilators for cirrhosis variceal bleed: Terlipressin/ Octreotide
  4. Antibiotics for cirrhosis: 3G cephalosporine or quinolones
  5. Prokinetics: IV erthromycin/ metoclopramide
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14
Q

Upper endoscopy for UGIB

Key timing for intervention

A

Hemodynamically stable - within 24h

Hemodynamically unstable/ variceal bleed - within 12h

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15
Q

Ddx UGIB by variceal bleed and non-variceal bleed

A

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
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16
Q

Ulcer UGIB

  • Locations
  • Major causes
  • Classification
A

Location: Duodenal, gastric, stomal ulcers

Major causes: H. pylori, NSAID/ aspirin, Stress (ICU)

Classification: Forrest Classification

17
Q

Gastritis/ Duodenitis/ Erosions

  • Associated causes
A
  • 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

18
Q

Esophageal/ gastric varices

Causes

A

Liver cirrhosis

Non-cirrhotic portal hypertension

Splenic vein thrombosis (isolated gastric varices)

19
Q

Esophagitis/ Esophageal ulcers

Causes

A

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

20
Q

Angiodysplasia and UGIB

Typical location

Variants

Associated conditions

A

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)
21
Q

Treatment modalities for UGIB

A

Endoscopic:

  • Adrenaline injection
  • Thermocoagulation - heat probe
  • Hemoclips
  • Argon plasma coagulation
  • Band variceal ligation/ sclerotherapy
  • n-butyl-2-cyanoacrylate tissue adhesive
22
Q

Aspirin should be discontinued for a period after PU bleed

True or false?

A

False

Early resumption of aspirin does not increase rebleeding risk with PPI coverage

Benefit: Definite reduction in mortality

23
Q

Second-line investigations for OGD negative patients with severe*** GIB (3 modalities)

A

Red cell scan

CT angiography

Angiography

24
Q

Second-line investigations for endoscopy -ve with Severe*** GIB

Compare pros and cons, complications

A

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
25
Q

Second-line investigations for endoscopy -ve, subacute** GIB

Compare advantages of each modality

A

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)

26
Q

Indications of video capsule endoscopy

Contraindications

Complications

A

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
27
Q

Compare single vs double balloon enteroscopy

Advantages for each technique

A

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
28
Q

Merkel’s scan

Function

Limitations

A

IV Tc-99m pertechnetate adhere to gastric mucosa

Scintigraphy can identify diverticula containing ectopic gastric mucosa

Limitations:

Cannot detect active bleeding

MBBS IV - Junior Clerkship WCS (131 decks)

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