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Lecture week 4 > Upper GI bleed > Flashcards

Upper GI bleed Flashcards

1
Q

Causes of upper GI bleed (oesophageal)

A

Oesophageal causes of upper GI bleed

  • varies
  • oesophagitis
  • cancer
  • Mallory-Weiss tear
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2
Q

Causes of gastric bleeding

A
  • gastric Ca
  • diffuse erosive gastritis
  • Dieulafoy lesion
  • gastric ulcer
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3
Q

What is the most common cause of major upper GI hemorrhage?

A

Posteriorly sided duodenal ulcer

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4
Q

What should patients with suspected varices receive propr to the endoscopy

A

Terlipressin - it is a vasopressin analogue -> vasoconstriction caused

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5
Q

Management of upper GI bleed

A
  • early control of airway + resuscitation if needed
  • investigate: bloods, upper GI endoscopy within 24 hours
  • further Rx depends on the cause of hemorrhage

-

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6
Q

Treatment of oesophageal varices causing upper GI bleed

A
  • banding
  • sclerotherapy

If these do not work:

Sengaksten- Blakemore tube (or Minnesota tube)

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7
Q

Treatment of patients with erosive oesophagitis / gastritis

A

Erosive oesophagitis/ gastritis Rx

  • proton pump inhibitor
  • identifiable bleeding points -> combination therapy of injection of adrenaline and either a thermal or mechanical treatment.
  • all patients 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.

* Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy

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8
Q

Which vessel is usually involved in the bleeding in duodenal ulcer

A

Gastro-duodenal a.

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9
Q

which vessel is usually involved in the bleeding from the gastric ulcer

A

left gastric artery

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10
Q

What score is used to predict the severity of upper GI bleed? (if admission and endoscopy is needed)

A

Blatchford score

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11
Q

What are the components of Blatchford score assessment?

A

Patient’s: Hb, serum urea, pulse rate and BP

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12
Q

What indicates low and what indicates a high risk on Blatchford score?

A
  • patients with a score of 0 are low risk
  • all others are considered high risk and require admission and endoscopy
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13
Q

What to calculate following the endoscopy? Why?

A

Rockall score - to determine the patient’s risk of rebleeding and mortality

* A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge

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14
Q

Rx for Mallory Weiss tear

A
  • Mallory Weiss tears will typically resolve spontaneously
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15
Q

Surgical treatment for duodenal ulcer

A

Duodenal ulcer - surgery

  • Laparotomy, duodenotomy and under running of the ulcer

*duodenotomy - excision of parts or all of the duodenum

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16
Q

Treatment (surgical) for bleeding gastric ulcer

A
  • Under-running of the bleeding site - suture ligation /podwiazanie/ of the bleeding vessel
  • Partial gastrectomy-antral ulcer
  • Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery)
  • Total gastrectomy if bleeding persists
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17
Q

What does Haematochezia mean?

A

Haematochezia

/hematoczesja/

Passing fresh blood - blood does not have time to be altered

*passed usually PR

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18
Q

What two groups of meds are associated with upper GI bleed

A

Drugs to be asked about while taking a history from a patient with an upper GI bleed

A. Mucosal damage (e.g. NSAIDs)

B. Impaired hemostasis(e.g. Warfarin)

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19
Q

Drugs that may cause mucosal damage (contributing to an upper GI bleed)

A

Mucosal damage:

  • NSAIDs
  • COX 2 inhibitors
  • Prednisolone

*all steroids, all anti-inflammatory (e.g. Naproxen, Ibuprofen, Diclofenac)

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20
Q

Drugs that impair hemostasis (therefore may impact on upper GI bleed)

A

Drugs that impair haemostasis:

  • Warfarin
  • DOACs / NOACs
  • Heparin/LMWH
  • anti-platelets
  • clopidogrel
  • Aspirin
21
Q

What does support the diagnosis of GI bleed? (4)

A
  • Hx of melena
  • Melena on PR
  • ratio of blood urea nitrogen to serum -> urea will go up
  • creatinine greater than 30
22
Q

What is the Rockall score used for?

What is the Blatchford (Glasgow-Blatchford) score used for?

A
  • Rockall score -> to predict mortality
  • Glasgow - Blatchford -> to see who we need to admit
23
Q

What does go up with upper GI bleed?

A

Urea goes up

24
Q

What score on Blatchford scale would indicate the need for admission (and need for upper endoscopy)?

A

Score of 1 or more

(only score of 0 indicated low risk -> so pt can be discharged)

25
Q

What signs are suggestive of upper GI bleed?

A
  • are they hypotensive? (>15% postural drop)
  • tachycardia
26
Q

Classes of an acute haemorrhage

What is important to know?

A

Important: a patient with a significant bleed (1500 or above) will show signs

*Signs: tachycardia, hypotension, decreased urine output, reduced LOC

27
Q

How much blood is lost in an acute haemorrhage?

A

Class I (<750) 15%

Class II (750 - 1500) 15 - 30%

Class III(1500 - 2000) 30-40%

Class IV (>2000) >40%

28
Q

What do we need to consider in terms of hemorrhage in a patient who is on beta-blocker?

A

HR rate may not be up even with a significant bleed

29
Q

The lethal triad of coagulopathy - what does it involve?

A
  • hypothermia
  • acidosis
  • coagulopathy

(lethal triad applies to each acute bleeding)

30
Q

What Dx would be these elements in Hx indicative of?

  • NSAID use, previous ulcer, systemic illness
A
  • peptic ulcer disease
  • gastroduodenitis
31
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

  • Alcohol excess, chronic liver disease, spider naevi, jaundice, hepatosplenomegaly, encephalopathy, ascites
A

Varices/ portal hypertensive gastropathy

32
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

  • excessive retching and vomiting prior to haematemesis
A

Mallory-Weiss tear

33
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

  • weight loss, dysphagia
A
  • stricture
  • malignancy
34
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

  • chronic reflux, bisphosphonate use
A

Oesophagitis

35
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

Previous abdominal aortic aneurysm repair

A

aorto-enteric fistula

36
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

Chronic kidney disease

A

Vascular ectasia

  • dilated small blood vessels in pyloric antrum -> bleeding into intestine
  • it is known as ‘watermelon stomach’ - due to pattern of bleed and appearance
37
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

Recent ERCP

A

Post- sphincterotomy bleed

38
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

Peritonitis

A

Perforated ulcer

39
Q

What Dx of upper GI bleed would be these elements in Hx indicative of?

cachexia/lymphadenopathy

A

malignancy

40
Q

Investigations in pt coming with upper GI bleed

A
  • FBC -> hemoglobin may not be yet decreased in acute bleed
  • U+E -> to see urea levels (up in the bleed)
  • LFTs -> due to the impact of chronic liver disease
  • glucose -> check for hypoglycemia
  • G+S +/- cross match
  • ECG -> to see if bilirubin has an effect on the heart

- errect CXR -> to see for perforation

*G+S if pt reports bleeding but obs stable and appears well

* cross match - if pt is unstable

41
Q

Do we give PPI before the endoscopy?

A

Not according to NICE guidelines

*may affect the results of biopsy if to be taken during endoscopy

42
Q

Management of upper GI bleed (in general)

  • meds wise
  • non-meds wise
A

Meds:

  • IV Metoclopramide (anti-emetic)
  • IV nTerlipressin (if Hx suggestive of varices - to vasoconstrict)
  • blood transfussion -> if indicated
  • IV vitamin K/FFP/ platelets -> if indecated

Other:

  • endoscopic options
43
Q

Surgical options of management of upper GI bleed

A

Options depend on the source/cause of bleeding:

  • embolization (cut off blood supply to the bleeding)
  • TIPS
  • transplantation
44
Q

Risk factors for bleeding of the varices

A
  • variceal size -> the bigger they are - the more chances of bleed
  • the presence of endoscopic red color signs (e.g. cherry red spots, red markings)
  • active alcohol use
  • Child classification -> to classify severity of liver disease -> more severe = more likely to bleed
45
Q

What scale is used to classify the severity of liver disease?

A

The Child - Pugh classification

46
Q

Why do we give antibiotic for a patient with upper GI bleed?

A

When a patient is encephalopathic -> change of the gut bacteria (translocation) -> release of endotoxin into systemic circulation -> sepsis and hemodynamically unstable

47
Q

Thresholds and Mx for coagulopathy:

  • platelets
  • INR
  • aPTTr
  • Fibrinogen
A
48
Q

What to advice on the discharge of pt after upper GI bleed (if the cause was ulcer)

A
  • H-pylori treatment (if present)
  • Ulcers: PPI for an initial period of 6-8 weeks
  • Ulcers: stop NSAIDs/ Cox 2 inhibitor
  • Perhaps clopidogrel
  • if pt needs to take anti-inflammatory -> consider COX 2 inhibitor
  • if aspirin is needed -> prescribe PPI with it
  • repeat endoscopy in 6-8 weeks -> to ensure the healing and exclude malignancy

Lecture week 4 (18 decks)

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