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Y4 Gastrointestinal > Upper GI bleeding > Flashcards

Upper GI bleeding Flashcards

1
Q

Generally how do patients with upper GI bleeding present ?

A
  • Haematemesis &/or malaena
  • Epigastric discomfort
  • Sudden collapse
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2
Q

What are the oesophageal causes of upper GI bleeding ?

A
  • Oesophagitis
  • Oesophageal varices
  • Malignancy
  • Mallory-weiss tear
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3
Q

What are the gastric causes of upper GI bleeding ?

A
  • Gastric ulcer
  • Gastritis/ gastric erosions
  • Gastric cancer
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4
Q

What are the dudodenal causes of upper GI bleeding

A
  • Duodenal ulcer
  • Erosive duodenitis
  • Aorto-enteric fistulation
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5
Q

What is a peptic ulcer ?

A

The overall term for gastric & duodenal ulcers

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6
Q

What are the features suggestive of oesophagitis causing an upper GI bleed ?

A
  • Small volume of fresh blood, often streaking vomit
  • History of GORD symptoms
  • Malaena rare.
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7
Q

Does oesophagitis causing GI bleeding usually require intervention ?

A

No usually ceases spontaneously

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8
Q

What are the features suggestive of a oesophageal malignancy causing upper GI bleeding ?

A
  • Usually small volume of blood, except as pre terminal event with erosion of major vessels.
  • Often associated symptoms of dysphagia and constitutional symptoms such as weight loss, fatigue etc.
  • May be recurrent until malignancy managed.
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9
Q

What are the features suggestive of a mallory weiss tear causing upper GI bleeding ?

A
  • Persistent vomiting/retching causes an oesophageal tear resulting in haematemesis
  • Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting.
  • Malaena rare.
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10
Q

Does a mallory weiss tear usually require intervention ?

A

No usually ceases spontaneously

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11
Q

How do oesophageal varcies arise ?

A
  • They are caused by anything which causes portal hypertension
  • This results in collateral formation between the portal and systemic venous systems (in the lower oesophagus)
  • These collaterals are prone to bleed profusley and repeatedly
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12
Q

When should you have a high clinical suspicion of oesophageal varices in someone with upper GI bleeding ?

A
  • If the patient has a history of alcohol abuse or cirrhosis (from metabolic, autoimmune or hepatitis liver disease).
  • Or signs of chronic liver disease - encephalopathy, splenomegaly, ascites, hyponatraemia, coagulopathy, thrombocytopenia
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13
Q

What are the typical features of upper GI bleeding caused by oesophageal varices ?

A
  • Usually large volume of fresh blood.
  • Swallowed blood may cause malaena.
  • Often haemodynamically compromised.
  • May stop spontaneously but re-bleeds are common until appropriately managed.
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14
Q

What are the typical features of upper GI bleeding which would suggest a gastric cancer as the cause ?

A
  • May be frank haematemesis or altered blood mixed with vomit.
  • Usually prodromal features of dyspepsia (indegestion) and may have constitutional symptoms.
  • Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.

If dyspepsia with ALARM Symptoms then worry about gastric cancer

  • Anaemia (iron deficiency)
  • Loss of weight
  • Anorexia
  • Recent onset of progressive symptoms
  • Melaena / haematemesis
  • Swallowing difficulty
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15
Q

What is erosive gastritis and duodenitis

A

Gastritis occurs when the lining of the stomach becomes inflamed after it’s been damaged.

Same but for duodenum

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16
Q

List the common causes of erosive gastritis and duodenitis

A
  • Bacterial - H. pylori bacterial infection
  • Chemical - Excessive use of cocaine, alcohol or NSAID’s
  • Autoimmune
  • Acutely - a stressful event such as a bad injury or critical illness, or major surgery
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17
Q

What are the typical features of GI bleeding caused by erosive gastritis or duodenitis?

A
  • Haematemesis
  • Epigastric pain/tenderness often related to hunger, specific foods/times of the day
  • May be associated bloating or heartburn
  • Usually there is an underlying cause e.g. NSAID’s
  • Large volume haemorrhage may occur with considerable haemodynamic compromise
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18
Q

What features would suggest autoimmune gastritis ?

A
  • Presence of anti-parietal and anti-intrinsic factor antibodies
  • Pernicious anaemia, macrocytic, due to B12 deficiency
19
Q

What is the treatment of erosive gastritis or duodenitis?

A
  • Manage stress
  • H.pylori tripple therapy eradication if they are positive
  • PPI’s (most effective) or H2 blockers e.g. ranitidine
20
Q

What complications can develop from erosive gastritis and duodenitis ?

A
  • Peptic ulcer formation - Gastric or dudodenal
21
Q

What other complications can develop from gastritis besides ulcers ?

A

Increases risk of Gastric carcinoma or gastric lymphoma

22
Q

What is a gastric ulcer ?

A

An open sore that develop on the lining of the stomach.

23
Q

What are the risk factors for gastric ulcer development ?

A
  • H.pylori infection
  • Old age
  • NSAID’s
  • Smoking
  • Reflux
24
Q

What are the typical features of upper GI bleeding caused by a gastric ulcer ?

A
  • Asymptomatic or epigastric pain (indigestion) +/- worsened by eating +/- relieved by antacids +/- Weight loss
  • Iron deficiency anaemia - Small low volume bleeds more common
  • Erosion into a significant vessel may produce considerable haemorrhage, haematemesis and haemodynamic compromise
25
Q

What is the most common cause of upper GI bleeding ?

A

Duodenal ulcer

26
Q

What are the clinical features suggestive of a duodenal ulcer ?

A
  • Haematemesis, malaena and epigastric discomfort/tenderness
  • The pain of duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating, before eating or at night
  • Pain is relieved by eating or drinking milk
27
Q

What are the clinical features suggestive of aorto-enteric fistulation causing upper GI bleeding ?

A

Major upper GI haemorrhage presenting in patients with previous AAA surgery

28
Q

How is H.pylori infection tested for ?

A

A carbon‑13 urea breath test or a stool antigen test

29
Q

What is the tripple therapy used for H.pylori eradication ?

A
  • A PPI + amoxicillin + either clarithromycin or metronidazole.
  • (if penicillin allergy then clarithro + metronidazole used)
30
Q

In people with peptic ulcer disease at high risk (previous ulceration) and for whom NSAID continuation is necessary, what alternative should be given?

A

A COX-2 selective NSAID

31
Q

What is the initial management of someone presenting with upper GI bleeding ?

A

Resuscitation:

  • ABC, wide-bore IV access both arms
  • Do cross match blood, check FBC, LFTs, U+E and Clotting
32
Q

When should platelet transfusion be considered in someone with upper GI bleeding ?

A

If actively bleeding with a platelet count of < 30 x 10*9/litre

33
Q

When should FFP be considered to be given to someone with upper GI bleeding ?

A

FFP to patients who have either a fibrinogen level of less than 1 g/litre, or a PT (INR) or activated PTT > 1.5 times normal

34
Q

What should be given to patinets on warfarin who are actively bleeding with a upper GI bleed?

A

Prothrombin complex concentrate

35
Q

What risk assessments should be done on someone with a upper GI bleed and when ?

A
  • use the Blatchford score at first assessment, and
  • the full Rockall score after endoscopy

Pic shows blatchford score

36
Q

Patients with a blatchford score of 0 should be considered for what?

A

Early discharge

37
Q

In patients who are unstable with upper GI bleeding, what should be done immediately or intandem with resuscitation measures?

A

Endoscopy

38
Q

What is the acute management of variceal bleeding ?

A

1st line = IV terlipressin + antibiotics (co-trimaxazole)

Followed by endoscopic variceal band ligation (EVL) - note sclerotherapy is worse

  • 2nd line = Sengstaken Blakemore tube if EVL fails
  • 3rd line = Transjugular intrahepatic portosystemic shunt (TIPSS) if above measures fail
39
Q

What is the prophylactic treatment of oesophageal varices ?

A
  • Propanolol to decrease rebleeding & mortality
  • EVL at 2 weekly intervals until all varices eradicated
  • IV PPI infusion given for 72hrs
40
Q

What is the management of non-variceal bleeding (mainly peptic ulcers)

A
  • PPI’s not given prior to endoscopy, only given if stigmata of recent haemorrhage seen on endoscopy (active bleeding, overlying clot, visible vessel) OR actively bleeding (refer to initial Mx of UGIB on blatchford score)
  • Endoscopy - identifiable bleeding points should recieve a combo of adrenaline injection & either a thermal or mechanical tx (heater prob coagulation, clips, hemospray)
  • If endoscopic intervention done then give a IV PPI infusion for 72hrs
41
Q

Bleeding peptic ulcers that cannot be controlled endoscopically may require what ?

A

Surgery:

  1. Gastric ulcer - requires partial gastrectomy or under running of the ulcer. If bleeding persists however total gastrectomy needed
  2. Duodenal ulcer - requires laporotomy ==> duodenectomy & under running of the ulcer
42
Q

What may patients with diffuse erosion gastritis require if bleeding cannot be controlled endoscopically ?

A

Gastrectomy

43
Q

Following IV PPI infusion and treatment of peptic ulcer bleeding what may then need to be done ?

A

H.pylori eradication and oral PPI

44
Q

Following endoscopy for upper GI bleeding a Rockhall score is done, if it is ≤ 3, what is permitted ?

A

Early discharge because risk of re-bleeding is low

Y4 Gastrointestinal (28 decks)

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