Upper gastro intestinal bleeding Flashcards
What are the common causes of Upper gastrointestinal bleeding
Oesophagitis
Gastritis
Duodenitis
Peptic ulcer disease
Varices
Mallory Weis
Malignancy and other
What are the risk factors for UGIB
NSAID and anticoagulant use
Chronic illness
Age older than 65
Poor socioeconomic status
Previous UGIB
Smoking
What should you do on initial assessment
Start with airway and breathing
The check circulation:
- History
- Magnitude of bleed
- Pre-existing deficit or ongoing loss
- Haemorrhagic shock
- Haematocrit and Hb are misleading
What should be done to localise the bleed
All patients with a significant bleed should recieve an upper endoscopy within 24hours
Whata re the management principles of peptic ulcer disease
Endoscopy within 24hours of onset
PPI - reduced rate of bleed
Forrest classification
Endoscopic haemostasis in Forrest 1-2a
Clot removal and evaluation in Forrest 2B
Medical:
- H pylori eradication
- Stop NSAIDs and smoking
Endoscopy:
- Combination therapy mandatory
- Epinephrine injection in all four quadrants
- Thermal therapy
- Hemoclips for spurting vessels
What are the indications for peptic ulcer disease surgery
Haemodynamic instability
Failed endoscopy therpay
Recurrent haemorrhage with shock
Continued bleeding requiring >3units/day
What is Mallory Weiss tears
Mucosal/submucosal tears near gastroesophageal junction secondary to retching and vomiting
Mechanism: Secondary to forceful contraction against relaxed cardia
Diagnosed on history, mostly self-limiting
What is stress gastric bleeds and the management thereof
Multiple superficial erosions most common in the corpus of the stomach
Commonly assiociated with NSAID use and hypoperfusion states
Management:
- Shock and early acid suppresive therapy
- Rarely needs endoscopic management
What is the management of oesphagitis bleed
Acid suppresion with PPI
Endoscopic control
Targeted therapy infections
What is a Dieulafoy lesion and the management thereof
Vascular malformation along the lesser curvature of the stomach up to 3mm in size within the submucosa
Can lead to massive bleeds
Management:
- Endoscopic using thermal or sclerosant therapy
- Angioembolisation in failed endoscopy
- Surgical over sewing is the last option
What is an aorto-enteric fistula, how does it present and how is it treated
Aorto-enteric fistula is defined as an abnormal connection between the gastrointestinal system and the aorta and is most common after graft erosion following the repair of abdominal aortic aneurysms
Presents with herald bleed and then massive haemorrhage typically seen in 3rd/4th part of the duodenum at endoscopy
Surgery involves proximal aortic ligation with extra-anatomical repair, removal of graft and duodenal closure
What is a haemobilia?
Hemobilia refers to bleeding from and/or into the biliary tract and is an uncommon but important cause of gastrointestinal haemorrhage
Associated with trauma, recent biliary tree instrumentation or hepatic neoplasms
May present with a trio of jaundice, right upper quadrant pain and GI haemorrhage
What is haemosuccus pancreaticus
A rare cause of upper GI bleeding from the pancreatic duct following erosion of pancreatic pseudocyst into the splenic artery
What is the pre-endoscopic management of bleeding from portal hyprtension
Permissive hypotensive resus and early ICU admission
Aggresive coagulation defect correction
Ceftriaxone for 7days emperically
Somatostatin analogue
What does the endoscopic management of bleeding from portal hypertension entail
Sclerotherapy:
- Technically easy but associated with perforations, mediastinitis and stricture formation
Banding has a low complication rate and is the procedure of choice
Gastric varices poorly managed by endoscopy
