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Stage 2: Inflammation > Upper GI Bleeding > Flashcards

Upper GI Bleeding Flashcards

1
Q

What might be a presentation of someone with variceal bleeding?

A
  • History of alcoholic liver disease
  • Haematemesis (fresh red blood)
  • Low BP
  • Feels light headed
  • Peripherally cold
  • Pale
  • Cap refill 5 seconds
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2
Q

What would you want to investigate in someone with variceal bleeding?

A
  • HR
  • GCS
  • Urine output (fluid status)
  • PMH
  • How much haematemesis and what colour (if coffee then not a sign anything is wrong on its own or acute bleed)
  • Any malaena
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3
Q

What does high HR and low BP indicate?

A

Class 3 shock, 50% blood volume lost

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4
Q

What is malaena?

A

Passage of loose black stool indicating fresh blood aka black diarrhoea (check with rectal exam)

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5
Q

How would you manage someone with an acute variceal bleed?

A
  • 2 large bore IV cannulas (worried about haemodynamic instability, needs fluid)
  • Take bloods incl. cross matching if need to give bloods
  • IV fluids
  • ABG
  • Insert catheter for hourly UOP
  • Keep NBM if need to get endoscopy
  • Frequent observations
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6
Q

What clotting value do you want to aim for?

A

INR < 1.5

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7
Q

How would you treat someone with acute variceal bleeding?

A
  • Stop offending drugs
  • Need blood?
  • Correct clotting
  • Platelet transfusion
  • Consider abx if risk of aspiration or varices
  • Supportive care - often stop bleeding on their own by the time put endoscope in
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8
Q

When do you transfuse a patient according to the restrictive strategy?

A

When Hb < 70 g/L

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9
Q

When do you transfuse a patient according to the liberal strategy?

A

When Hb < 90 g/L

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10
Q

How would you treat a non-variceal bleed (peptic ulcer)?

A

Proton pump inhibitors (pantoprazole infusion) - useful in healing process

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11
Q

What medication would you use to treat a variceal bleed?

A

Terlipressin - reduces blood supply to varices (causes vasoconstriction) or co-amoxiclav

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12
Q

What is the most common cause of UGI bleeding?

A

Peptic ulcer

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13
Q

What are the causes of UGI bleeding?

A

1) Mallory-Weiss tear
2) Oesophagitis/gastritis
3) Oesophageal varices
4) Peptic ulcer
5) Malignancy
6) Drugs
7) Angiodysplasia
8) Aorto-enteric fistula

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14
Q

What are the top 4 causes of UGI bleeding?

A

Peptic ulcer, oesophagitis, Mallory-Weiss tears and oesophageal varices

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15
Q

What causes oesophagitis?

A

Acid reflux or doxycycline

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16
Q

What is the most common type of peptic ulcer?

A

Duodenal

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17
Q

What should you always ask about in someone with a peptic ulcer?

A

NSAID history

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18
Q

What is malignancy more likely to present with than bleeding?

A

Pain and dysphagia

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19
Q

What is angiodysplasia?

A
  • Abnormal vessels in mucosa and sub-mucosa of the UGI tract which suddenly bleed bc they are fragile esp. in people with heart conditions
  • More common in > 60 years
  • Secondary to mucosal ischaemia or low grade obstruction of mucosal veins
  • Possible link with aortic valve disease (Heyde’s syndrome)
  • Usually radiate out from central vessel
  • Can just be red spots
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20
Q

What drugs can cause UGI bleeding?

A
  • NSAIDs
  • Aspirin
  • Anticoagulants (clopidogrel)
  • Steroids
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21
Q

What is the Blatchford score useful for?

A

Identifies patients that require clinical intervention e.g. endoscopy or blood transfusion (how emergent they are)

22
Q

What does a Blatchford score ≥ 6 mean?

A

There is > 50% risk they will need an intervention

23
Q

What can be mistaken for malaena?

A

Dark brown solid stool due to iron

24
Q

When does someone with a severe bleed (Blatchford ≥ 6 or ongoing haemodynamic instability) need an OGD?

A

Urgent one resuscitated (need protected airway)

25
Q

When does someone with mild/moderate bleed or malaena need an OGD?

A

Within 24h of admission

26
Q

What should you give 30 mins before an OGD and why?

A

250mg IV erythromycin to get blood out of GI tract so can see better

27
Q

What kind of treatments can you give to stop bleeding when doing an endoscopy?

A
  • Clip an exposed vessel in the middle of a peptic ulcer and inject adrenaline straight into the ulcer
  • Burn vessels
  • Banding e.g. of pseudo-polyp - will scar on its own, stops bleeding upstream immediately
28
Q

How many types of therapy should you give to stop bleeding?

A

2

29
Q

How do you manage a patient after an OGD?

A
  • Continue PPI, terlipressin and abx
  • Rockall score
  • Clear fluids after 1h
  • Light diet after 6h
  • Monitor for signs of re-bleeding
  • Only keep NBM for one day
  • Keep patient on ward
30
Q

What do you do when the bleeding can’t be controlled?

A

Put in coils, embolise or involve surgery

31
Q

What is the aim of the Rockall score?

A

To identify risk factors to predict mortality and risk of re-bleeding

32
Q

What Rockall score carries a good prognosis?

A

< 3

33
Q

What Rockall score carries a high risk of mortality?

A

> 8

34
Q

What other things would you do to treat a peptic ulcer?

A
  • Check and eradicate H. pylori
  • Omeprazole 40mg OD/BD 8 weeks
  • Repeat scope in 6-8 weeks if gastric ulcer
  • Stop smoking
  • Risk of malignancy (not direct)
35
Q

What other things would you do to treat varices?

A
  • Propranolol or carvedilol

- Endoscopic banding every 2-4 weeks

36
Q

What is a Mallory-Weiss tear?

A
  • GOJ (gastro oesophageal junction) laceration secondary to retching
  • 80-90% stop spontaneously
37
Q

How do you treat a Mallory-Weiss tear if it doesn’t stop spontaneously?

A

Same as peptic ulcer - clipping, burning, injecting adrenaline

38
Q

What are peptic ulcers commonly related to?

A
  • H. pylori
  • NSAIDs
  • Hypersecretory (gastrinoma)
39
Q

What classification is used to decide who needs therapy for peptic ulcers at the time of endoscopy?

A

Forrest’s

40
Q

What is used to test for H. pylori?

A
  • CLO (biopsy + rapid urease test)
  • Urea breath test
  • Serum IgG and stool antigen
41
Q

What is the treatment for H. pylori?

A

7 day triple therapy of PPI + amoxicillin + metronidazole

42
Q

What are oesophageal varices due to?

A

Portal hypertension due to chronic liver disease (first bleeds carry 25-50% mortality)

43
Q

Where else can varices be found?

A

Stomach, rectum, duodenum

44
Q

What may be needed to treat oesophageal varices?

A

TIPSS (transjugular intrahepatic portosystemic shunt)

45
Q

What type of cancers are > 90% of gastric cancers?

A

Adenocarcinoma

46
Q

What are risk factors for gastric cancer?

A
  • H. pylori
  • Smoking
  • Preserved food
  • Genetics
47
Q

Why do gastric cancers have poor outcomes (5 year survival 20%)?

A

They often grow into lumens which don’t really transmit pain

48
Q

What are two common types of oesophageal cancer?

A

Squamous cell carcinoma and adenocarcinoma (late presentation is common)

49
Q

What are 3 risk factors for oesophageal cancer?

A
  • Barrett’s
  • Achalasia
  • Betel nuts
50
Q

What is gastritis (unlikely cause of bleeding) associated with?

A
  • NSAIDs
  • Alcohol
  • TB
  • H. pylori

Stage 2: Inflammation (39 decks)

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