Upper GI Bleeds Flashcards
What are the 3 main arteries supplying the GIT and what structures do they supply?
Celiac trunk= foregut
- distal oesophagus to ampulla of Vater of 2nd part of duodenum
- liver
- gall bladder and biliary tree
- spleen
- pancreas
- greater and lesser omentum
Superior mesenteric artery= midgut
- from ampulla of Vater of 2nd part of duodenum to splenic flexure of large bowel
- head of pancreas via inferior pancreaticoduodenal artery
Inferior mesenteric= hind gut
-from splenic flexure of transverse colon to upper anal canal
What are the risk factors for upper GI bleeds?
Asparin NSAIDs Warfarin Liver disease Increased age i.e. increased from with each decade of life H. Pylori
Why are upper GI bleeds associated with higher mortality rate compared with lower GI bleeds?
Increased risk of damage to artery due to ulcer erosion or oesophageal varices which leads to increased volume or rate of blood loss
Where can a bleed be located to be classified as an upper GI bleed?
oesophagus, stomach, duodenum
How might someone with an upper GI bleed present?
Haematemesis i.e. vomiting blood
Coffee- ground vomit i.e. vomiting digested blood
Melaena= black, tarry, offensive stool due to digested blood
Collapse
Anaemia
Abdo pain
What are melaena not be used to indicate?
The severity/degree of bleeding
I.e. only 50ml required for melaena to present
What are the major causes of upper GI bleeds?
Gastric erosions Duodenal or gastric ulcers Oesophageal varices Mallory-Weiss tear Cancer Oesophagitis Dieulafoy’s lesion AV malformation Aorta-enteric fistula Haemobilia
What is haemobilia?
Blood in biliary tree which is then refluxed into stomach
Why can oesophagitis result in upper GI bleeding?
Weakened of lower oesophageal sphincter leads to reflux of gastric acid into oesophagus causing ulcer to form
I.e. ulcer can lead to damage to blood vessels
What is Mallory-Weiss Tear? How is it different to Boerhaave’s syndrome?
Tear in oesophageal mucus membrane due to forceful vomiting which leads to bleeding
BS= perforation of oesophagus which causes acute chest pain and subcutaneous emphysema
Why do oesophageal varices form?
Increased portal hypertension leads to back flow of pressure which causes dilatation of oesophageal veins to form varices
What type of duodenal ulcer would you be more concerned about if found during endoscopy?
Ulcer covered in clot rather than being clean ulcer
I.e. clot covering the end of an artery which is then at risk of re-bleeding if clot dislodged
Would a stomach ulceration present with bleeding? What are other possible presentations?
No
Caused by perforation of gastric ulcer w/o hitting artery which leads to gastric contents perforating into abdominal cavity
Severe abdo pain
Board-like rigidity
Pneumoperitoneum i.e. gas under the diaphragm
What clinical signs might indicate severe upper GI bleed?
Pulse >100 and BP <100mmHg i.e. haematologically unstable
Postural drop in BP i.e. decreased BV means unable to compensate for standing
Derranged INR
Drop in Hb
Why is a fall in Hb not the most sensitive way to assess for upper GI bleed severity?
Acute loss can take while to translate into fall int Hb due to it taking time for dilation to occur
What is the different between the Rockhall and Glasgow-Blatchford scoring system?
Rockhall= used when patient having endoscopy to assess the risk of re-bleeding
Glasgow-Blatchford= used to establish risk for patient having upper GI bleed based on their initial clinical presentation
What are the components used for the Blatchford score? What score indicates high risk of upper GI bleed?
Drop in Hb Rise in urea Low BP High HR Syncope Melaena
> 0
Why does urea rise in upper GI bleeds?
Blood broken down by acid and gastric enzymes which releases urea as breakdown product
Urea absorbed into gut which leads to risk in serum urea
What are the components of Rockhall scoring system and what are they used to calculate?
Age
Shock
Cormorbidites i.e. IHD/CCF/Renal or liver cancer
MW tear or cancer or other diagnosed cause
Signs of bleeding
Generates percentage risk for re-bleeding and mortality
What are upper GI bleeds managed?
ABATED
A= ABCDE for immediate resuscitation (oxygen) B= bloods (FBC, U+E, INR, LFTs and cross match) A= access via 2 large bore cannula T= transfuse (blood or platelets) E= endoscopy i.e. urgently arranged w/i 24 hrs D= Drugs i.e. stops NSAIDs and anticoagulents
What types of endoscopic therapy can be used in the case of upper GI bleeds?
Adrenaline injection to tamponade and vasoconstrict vessels
Metal clips
Heater probe
Coagulation powder sprays
How does pH effect clotting ability of blood? Therefore what drug therapy can be used as an adjunct in upper GI bleeds?
pH<6= pepsin activated which leads to lysing of clot pH<5= clotting not affective
IV omeprazole acts to maintain pH for 24hrs
What can be done to prepare a patient medically for OGD?
Tranexamic acid
Stabilise clots
NBM
Fluids
What event can trigger variceal bleeding and what can be done to decrease the risk of this occurring?
Bacteraemia
Prophylactic antibiotics
Why would patient with variceal bleeding by given Terlipressin?
2mg per 6 hrs
Synthetic analogue for vasopressin which acts to reduce portal pressure and therefore the variceal pressure to decrease the risk of bleeding
I.e. given BEFORE endoscopy
What is band ligation of varices?
Band passes around the neck of varices which encourages clotting in varices and for varices to fall off
When is banding not possible? What is the alternative endoscopic therapy for varices?
When blood is obstructing view so unable to ligate
Balloon tamponade: (severe circumstances)
-end guided into stomach and inflated which can aid to compress blood supply to varices
I..e used as bridging therapy before re-attempting OGD
Why is there a rise in urea with upper GI bleeds? What are the other differentials for raised urea?
The blood is digested to protein which is then metabolised to blood urea nitrogen (BUN) in the urea cycle of the liver i.e. urea will rise with increase digested blood
Differentials:
- AKI/CKD
- dehydration
What is important to ask as part of HX for PR or haematemesis?
Ask if patient on NSAIDs
-risk factor for peptic or gastric ulcers which can lead to bleeding
