Upper GI Bleed Flashcards
Upper GI bleeding is bleeding for a source proximal to which structure?
Ligament of Treitz
Define the ligament of Treitz
Ligament of Treitz is a band of peritoneum that is located at the junction between the duodenum and the jejunum
Is upper GI bleed more common in males or females
Males
Name the 7 risk factors for upper GI bleed
- Medications
NSAIDs
Anticoagulants
- Alcohol abuse
- Chronic liver disease
- Chronic kidney disease
- Advancing age
- H. pylori infection
What does NSAIDs inhibit the synthesis of?
Prostaglandins
Describe the pathogenesis of how NSAID use can cause an upper GI bleed
- NSAIDs inhibit the synthesis of prostaglandins, which are gastroprotective.
- Prostaglandins work by inhibiting enterochromaffin-like cells, which are involved in the secretion of histamine.
- Histamine stimulates parietal cells to secrete hydrochloric acid.
- Thus, inhibition of prostaglandins leads to excessive HCl secretion and damage to the underlying mucosa.
Name the 3 most common cause of upper GI bleed
Peptic ulcer disease
Gastritis
Oesophageal varices
Name some of the causes of an upper GI bleed from the oesphagus
- Oesophagitis i.e. inflammation of the oesophagus
- Oesophageal varices
- Malignancy
- Gastro-oesophageal reflux disease (GORD)
- Mallory-Weiss tear i.e. tear of the oesophageal mucous membrane
Name some of the causes of an upper GI bleed from the stomach
- Peptic ulcer disease
- Mallory-Weiss tear
- Gastric varices
- Gastritis i.e. inflammation of the stomach
- Malignancy
- Gastric ulceration
Name some of the causes of an upper GI bleed from the duodenum
- Peptic ulcer disease
- Diverticulum
- Aortoduodenal fistula
- Duodenitis i.e. inflammation of the duodenum
- Duodenal ulceration
Define Oesophagitis
Refers to inflammation of the intraluminal epithelial layer of the oesophagus
Oesophagitis affects which layer of the oesphageal wall
The intraluminal epithelial layer
Name the 6 causes of the Oesophagitis
Gastroesophageal reflux disease (GORD) -Most common
less common causes include:
Infections e.g. Candida Albicans
Medications e.g. bisphosphonates
Radiotherapy
Ingestions of toxic substances
Crohn’s disease
What is the definition of Oesophageal Varices
Refers to dilations of the porto-systemic venous anastomoses in the oesophagus
These dilated veins are swollen, thin-walled and hence prone to rupture
What is the most common underlying cause for oesophageal varices
Portal hypertension resulting from chronic liver disease/cirrhosis
Describe the pathogenesis of how portal hypertension can leads to oesophageal Varices
Increases in portal pressure leads to the development of a collateral circulation to overcome the obstruction to flow in the portal system
The lower end of the oesophagus forms an important ‘portacaval anastomosis’ which allows the flow of venous blood from the portal system to the systemic circulation
Define the term Mallory-Weiss Tear
It is a result of a forceful vomiting causing a tear in the epithelial lining of the oesophagus, resulting in a small bleed
What is the classic presentation of Mallory-Weiss Tear
Episodes of severe or recurrent vomiting, then followed by minor haematemesis
What is the management option for Mallory-Weiss Tear
Most cases are benign and will resolve spontaneously
If the patient with Mallory-Weiss Tear has a prolonged or worsening haematemesis. What should they be investigated with?
Oesophago-gastro-duodenoscopy (OGD)
Define the term “haematemesis”
Vomiting blood
Where does mallory-weiss occur
Tear of the tissue of your lower esophagus
Peptic ulcer disease can cause the development of which type of ulcers
Gastric and duodenal ulcers
How does a gastric or duodenal ulcer secondary to peptic ulcer disease cause an upper GI bleed
Occurs due to the erosion of the ulcer through into the blood vessels supplying the upper GI tract causing the bleeding
Peptic ulcer disease is strongly associated with which infection?
Helicobacter pylori infection
What are the two types of haematemesis
The vomiting of fresh blood
The vomiting of “coffee ground vomit” - where the blood is partially digested
What makes coffee ground vomit “coffee ground”?
It is coffee ground because the blood is partially digested
Define the term melanea
Passing of black tarry faeces discoloured by the presence of digested blood
Why is melaena black in colour?
The faeces are discoloured by the presence of digested blood
What are the key features of upper GI bleed
Haematemesis i.e. vomiting blood
AND/OR
Melaena
AND/OR
Features of shock e.g., hypotension, collapse
What two scoring stratification tools are used to identify high-risk patients and those that need prompt intervention in upper GI bleed
Glasgow-Blatchford score – primary assessment tool
Rockall score – useful after endoscopy
What scoring system is used as the primary assessment tool for patients presenting with upper GI bleeding:
Glasgow-Blatchford score
When should the Rockall scoring system be used in upper GI bleed
Post-endoscopy
Why does urea rise in upper GI bleeds?
The blood in the GI tract gets broken down by acid and digestive enzymes
One of the breakdown products is urea and this urea is then absorbed in the intestines.
Name the crtieria of the Blatchford score
- Drop in Hb
- Rise in urea
- Blood pressure
- Heart rate
- Melaena
- Syncope i.e. loss of consciousness
Name the criteria for the Rockall score
Mnemonic ABCDE
A- Age
B - BP and HR
C - Co-morbidities
D - Diagnosis
E - Endoscopic findings
What is the gold standard investigation for upper GI bleed
Upper GI endoscopy i.e. oesophago-gastro-duodenoscopy (OGD)
What is the management for upper GI bleeds
Mnemonic “ABATED”
A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 large bore cannula)
T – Transfuse
E – Endoscopy (arrange urgent endoscopy within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)
What is the most common cause of non-variceal upper GI bleed
Peptic ulcer disease
Name the endoscopic management options for non-variceal upper GI bleeds
Dual therapy at the time of endoscopy either:
Adrenaline AND Mechanical (clips)
OR
Adrenaline AND Therapy Coagulation
Name the endoscopic management options for variceal upper GI bleeds
Variceal band ligation (VBL)
Name the pharmacological management options for non-variceal upper GI bleeds
PPI
Name the pharmacological management options for variceal upper GI bleeds
Terlipressin (IV injection): to reduce portal pressures
Prophylactic antibiotic therapy: to reduce the risk of spontaneous bacterial peritonitis
Describe the mechanism of action of Terlipressin?
Terlipressin is an analogue of vasopressin (ADH)
It causes splanchnic vasoconstriction, which in turn reduces portal pressures
