List I - Act Core Conditions Flashcards
How can patients with upper GI bleeding present?
- Haematemesis and/or malaena
- Epigastric discomfort
- Sudden collapse
What are the oesophageal causes of bleeding?
- Oesophagitis
- Cancer
- Mallory-Weiss Tear
- Varices
What are the presenting features of oesophagitis?
- Small volume of fresh blood
- Often streaking vomit
- Malaena is rare
- Often ceases spontaneously
- Usually there is a history of antecedent GORD type symptoms
What are the presenting features of cancer causing upper GI bleeding?
- Usually small volume of blood - except pre-terminal event with major erosion of vessels
- Often associated with dysphagia and constitutional symptoms such as weight loss
- May be recurrent until the malignancy is managed
How does a Mallory Weis tear present?
- Typically brisk small to moderate volume bright red blood following bout of repeated vomiting
- Malaena rare
- Usually ceases spontaneously
What are the presenting features of varicies leading to upper GI bleed?
- Usually a large volume of fresh blood
- Swallowed blood may cause malaena
- Often haemodynamic compromise
- May stop spontaneously but re-bleeds are common until appropriately managed
What are the gastric causes of upper GI bleeding?
- Gastric cancer
- Dieulafoy lesion
- Diffuse erosive gastritis
- Gastric ulcer
What are the features of gastric cancer leading to gastric bleeding?
- Frank haematemesis or altered blood mixed with vomit
- Usually prodromal features of dyspepsia and may have constitutional symptoms
- Variable bleeding but erosion of major vessels may produce considerable haemorrhage
What is a Dieulafoy lesion?
- Large tortuous arteriole (AV malformation) most commonly in the stomach wall (sub mucosa) that erodes and bleeds
- Can be present in any part of the GI tract
What are the presenting features of a Dieulafoy lesion leading to gastric bleeding?
- Often no prodromal features prior to haematemesis and malaena
- May be difficult to detect endoscopically
What are the presenting features of diffuse erosive gastritis?
- Usually haematemesis and epigastric discomfort
- Usually there is an underlying cause such as recent NSAID use
- Large volume haemorrhage may occur with considerable haemodynamic compromise
What are the presenting features of a gastric ulcer?
- Small low volume bleeds more common so would tend to present as iron deficiency anaemia
- Erosion into a significant vessel may produce considerable haemorrhage and haematemesis
What can cause major haemorrhage to the duodenum?
- Most common cause of major haemorrhage to this site is a posteriorly sited duodenal ulcer
What are the presenting features of duodenal ulcer?
- Haematemesis
- Malaena
- Epigastric discomfort
How is the pain of a duodenal ulcer different to the pain of a gastric ulcer?
- Pain of a duodenal ulcer often occurs several hours after eating
What is the risk of patients with previous abdominal aortic aneurysm?
- Rare but important complication is:
- Aorto-enteric fistulation is associated with cause of major haemorrhage associated with high mortality
Which risk stratification tools can be used for patients with acute upper GI bleeding?
- Blatchford score (at first assessment)
- Consider early discharge for all patients with a pre-endoscopy Blatchford score of 0
- (full) Rockall score (after endoscopy)
What is the purpose and parameters of the Glasgow Blatchford score for upper GI bleeding?
- Purpose - use for adult patients being considered for hospital admission due to upper GI bleeding
- Parameters - haemoglobin, blood urea nitrogen (BUN), systolic BP, sex, HR, presence of malaena, recent syncope, hepatic disease history, cardiac failure present
What is the purpose and parameters of the Rockall score for upper GI bleeding?
- Purpose - for patients with clinical upper GI bleeding who have undergone endoscopy
- Parameters - age, shock, comorbidities, diagnosis, major stigmata of recent haemorrhage
What is the initial management of a patient with a suspected upper GI bleed?
- Admission to hospital
- A to E assessment
- Cross matched blood, check FBC, LFT’s, U+E and clotting (as a minimum)
- Patients with ongoing bleeding and haemodynamic instability are likely to require O negative blood pending cross matched blood (major haemorrhage protocol)
- Early control of airway is vital (e.g. drowsy patient with liver failure)
- Ideally all patients for upper GI endoscopy within 24 hours of admission (urgent after stabilisation in unstable patients)
How should patients with bleeding varices be managed?
- Patients with suspected varices should receive terlipressin prior to endoscopy
- Varices should be banded or subjected to scleropathy
- If banding is not possible owing to active bleeding then a Sengaksten-Blakemore tube (or Minnesota tube) should be inserted
- Should be done with care; gastric balloon should be inflated first and oesophageal balloon second, the balloon will need deflating after 12 hours (ideally sooner) to prevent necrosis, portal pressure should be lowered by combination of medical therapy +/- TIPSS
What medical management should patients with erosive oesophagitis / gastritis receive?
- Proton pump inhibitor
How are Mallory Weiss tears managed?
- Typically resolve spontaneously
- Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment. All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate
What are the indications for surgery for patients with upper GI bleeding?
- Patients >60 years
- Continued bleeding despite endoscopic intervention
- Recurrent bleeding
- Known CV disease with poor response to hypotension
What is constipation?
- Symptom based disorder which describes defecation that is unsatisfactory because of infrequent stool, difficulty passing stools or the sensation of incomplete emptying
What diagnostic criteria can be used for constipation?
- Rome IV criteria
- Spontaneous bowel movements occurring less than 3 times per week
- Stools often dry, hard or lumpy and may be abnormally large or small
- In reality, constipation is often defined as passage of stools less frequently than the persons normal pattern
What is chronic constipation?
- Symptoms which are present for at least 12 months in the preceding 6 months
What is faecal loading/impaction?
- Describes retention of faeces to the extent that spontaneous evacuation is unlikely
What is overflow incontinence?
- Encopresis or bypass soiling - leakage of liquid stool from the proximal colon around impacted faeces where small quantities of stool may be passed frequently and without sensation
What is functional (primary or idiopathic) constipation?
- Chronic constipation without a known cause
- Three physiological subtypes have been described which may overlap:
- Normal transit - most common, where there is constipation with no time delay in passage of stool through the colon
- Slow transit - prolonged delay in passage of stool through the colon
- Outlet delay (or obstructed defecation) can be caused by pelvic floor dyssynergia (the pelvic floor muscles are uncoordinated and contract rather than relax during attempted defecation
What is secondary (organic) constipation?
- Caused by medication or an underlying medical condition