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Yr3 Medicine- Gastroenterology > Upper GI Bleeding > Flashcards

Upper GI Bleeding Flashcards

1
Q

Discuss what you want to clarify when taking a GI bleed history

A
  • Haematemesis? (fresh blood in vomit)
  • Coffee ground vomit? (blood has been altered by gastric acid)
  • Malaena? (black, tarry, sticky stool)
  • Fresh PR bleed? (e.g. blood on toilet roll. Usually indicate lower GI bleed but may suggest brisk upper GI bleed)
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2
Q

Upper GI bleed is an emergency; true or false?

A

True

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3
Q

When we talk about upper GI bleeding we are referring to some form of bleeding from what 3 parts of GI tract?

A
  • Oesophagus
  • Duodenum
  • Stomach
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4
Q

State some potential causes for upper GI bleeds- highlight most common causes (2 most common)

A

Oesophageal causes

  • Oesophageal varices
  • Mallory-Weiss tear
  • Oesophageal cancer
  • Oesophagitis

Gastric & duodenal causes

  • Peptic ulcers
  • Gastric cancer
  • Vascular malformations (e.g. dieulafoy lesion)
  • Diffuse erosive gastritis
  • Aorto-enteric fistula
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5
Q

Summary of oesophageal causes

A
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6
Q

Summary of gastric causes

A
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7
Q

Summary of duodenal causes

A
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8
Q

What are the signs/typical presentation of an upper GI bleed?

A
  • Haematemesis
  • Coffee-ground vomit
  • Malaena
  • Abdo pain
  • Dizziness (especially postural)
  • Fainting
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9
Q

What might you find on clinical examination of someone with an upper GI bleed?

A
  • Hypotensive
  • Tachycardic
  • Decreased urine output
  • Slow capillary refill
  • Cool & clammy
  • Signs relating to underlying cause e.g. jaundice or ascites in liver disease
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10
Q

What signs would indicate that your pt with upper GI bleed is in shock?

A
  • Pulse >100bpm
  • Systolic bp <100mmHg or postural drop >20mmHg
  • Cool & clammy peripheries
  • Cap refill >2/3 secs
  • Urine ouput <0.5mL/kg
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11
Q

There are two scoring systems that you can use in an upper GI bleed; state the name of each and why you would use each one

A
  • Glasgow-Blatchford score: establishes risk of pt having an upper GI bleed to help you make a plan e.g. admit or discharge them, what interventions they might need e.g. blood transfusion, endoscopy
  • ROCKALL score: split into pre- and post-endoscopy score and predicts the risk of re-bleeding and mortality from an upper GI bleed
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12
Q

What factors does the Glasgow-Blatchford score consider?

A
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13
Q

What factors does the pre-endoscopic ROCKALL score consider?

A
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14
Q

What factors does the post-endoscopy ROCKALL score consider?

A
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15
Q

What is a Mallroy-Weiss tear?

A

Tear in mucosa of oesophagus- often at junction between oesophagus & stomach. Pathogenesis is not fully understood but are often seen following sudden chagne in pressure gradient across gastro-oesphageal junction e.g. following retching/vomiting, coughing etc..

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16
Q

Why does the urea rise in an upper GI bleed?

A

Blood in GI tract gets broken down by acid & enzymes; one of the breakdown products is urea. This urea is then absorbed in the intestines.

17
Q

Summarise the management of an acute upper GI bleed

*Think ABATED

A
  • A-E for immediate resuscitation
  • Bloods
  • Access (2 large bore cannulas)
  • Transfuse
  • Endoscopy (arrange urgent endoscopy within 24hrs)
  • Drugs (stop anticoagulants, NSAIDs… AND extra drugs for oesophageal varices, extra drugs for warfarin)
18
Q

What blood tests do you need to do in an upper GI bleed?

A
  • FBC: Hb, platelets (thrombocytopenia may be suggestive of liver disease)
  • U&E: raised urea supports upper GI bleed diagnosis
  • Clotting/coagulation: abnormal clotting should be corrected to help bleed
  • LFTs: help you think about cause; however remember normal LFTs doesn’t rule out chronic liver disease
  • Crossmatch or Group & save: you may need to transfuse blood
19
Q

Why do a VBG in upper GI bleed?

A

VBG can give you Hb result more quickly than FBC

20
Q

What is the difference between ‘Group & Save’ and ‘crossmatch’

A
  • “Group & save”: lab checks pts blood group and keeps a sample of their blood saved in case they need to match blood to it
  • “Crossmatch”: lab actually finds blood, tests that it is compatible and keeps it ready in fridge to be used if necessary
21
Q

If your pt is haemodynamically unstable, what would you opt for: “Group & Save” or “Crossmatch”

A

Crossmatch 2 units of blood

22
Q

What is the most important step in managing pts with upper GI bleeding?

A

Deciding the likelihood that bleeding is due to oesophageal varices as this requires extra treatment

23
Q

What can you give to pts that are taking warfarin and are actively bleeding?

A

Prothrombin complex concentrate (source of vitamin K dependent clotting factors (II, VII, IX, X, and antithrombin proteins C & S)

24
Q

Why would you give pts presenting with upper GI bleed prothrombin complex concentrate over vitamin K?

A

Vitamin K takes too long to work; in acute upper GI bleed need quick reversal of effects of warfarin

25
Q

Transfusion is based on individual presentation, state:

  • Three ‘things’ you can transfuse
  • When you should consider transfusin each
A
  • Packed red cells: if significant Hb drop (<70g/L)
  • Platelets: platelets <50x 109/L
  • Clotting factors/fresh frozen plasma: FFP if fibrinogen <1g/L or PT or APTT >1.5x normal
  • Prothrombin complex: reversal of warfarin
26
Q

We have already mentioned that upper GI bleeds due to varices require some extra treatment; discuss the extra treatment required if upper GI bleed is due to varices

A
  • Avoid saline as resuscitation fluid if pt has cirrhosis/varices
  • IV Terlipressin (1-2mg/6hr)
  • Prophylactic broad spectrum IV antibiotics
27
Q

State two contraindications to IV terlipressin use in suspected variceal bleeds

A
  • Ischaemic heart disease
  • Peripheral vascular disease
28
Q

Describe the mechanism of action of terlipressin and hence explain why it works in the treatment of oesophageal varices

A
  • Synthetic vasopressin analogue which preferentially binds to V1 receptor which are found in splanchnic vasculature causing vasoconstriction of splanchnic vasculature leading to reduction in portal pressure
29
Q

Systolic blood pressure is often low in pts with cirrhosis; true or false?

A

True; may be important to remember this when determining if you have restored bp to normal in pts with cirrhosis

30
Q

Describe 3 definitive treatment options for variceal bleeding; what is the aim/main mechanism of each of these treatments

A

Want to mechanically obstruct blood flow through the varices:

  • Oesophageal banding: put band around varices to stop blood flow to them. Tissue that was banded with slough off and pt may pass bands in their stools.

​…if banding doesn’t work)

  • Linton or Sengstaken-Blakemore tube as a TEMPORARY MEASURE: see image- basically a balloon that stops bleeding
  • …..or*
  • TIPSS [Trans-jugular intrahepatic porto-systemic shunt): shunt between hepatic and portal vein to prevent portal hypertension
31
Q

Non-variceal bleeding is most commonly caused by peptic ulcer disease but various vascular malformations can also cause upper GI bleeding; state soem examples of vascular malformations

A
  • Angiodysplasia: a degenerative vascular malformation of the gastrointestinal tract characterised by fragile and leaky blood vessels. Usually in right side of colon.
  • Dieulofoys:dilated tortuous submucosal artery that erodes overlying gastrointestinal mucosa most commonly found in the stomach.
32
Q

Most upper GI bleeds that are NOT caused by varices often stop bleeding on their own; true or false

A

True

33
Q

Discuss the use of PPI prior to endoscopy in upper GI bleeds

A
  • Not reccomended by NICE but some senior doctors may give this (80mg IV omeprazole)
  • Work by reducing gastric acid secretion, neutralizing gastric pH, stabilising clot and stopping bleeding
34
Q

What % of pts who re-bleed will die?

A

40%

35
Q

Discuss the management of upper GI bleeds post endoscopy

A
  • ROCKALL post endoscopy score to look at risk of rebleed
  • Monitor closely checking vital signs every 15 mins
  • Treat cause of bleeding as best you can e.g. treat varices, treat H-pylori if caused peptic ulcer etc…
36
Q

State some signs of a re-bleed

A
  • Rising pulse rate
  • Falling JVP
  • Falling urine output
  • Haematemsis or fresh malaena
  • Fall in BP
37
Q

Is it normal to pass malaena in the 24hr period following an upper GI bleed?

A

Yes, as some of blood will have made its way down GI tract. HOWEVER, amounts of malaena should be decreasing. Must monitor closely and keep eye out for other signs of rebleed

38
Q

Recap how you treat acute upper GI bleed

  • *Oxford handbook diagram*
  • *Think ABATED*
A

Yr3 Medicine- Gastroenterology (8 decks)

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