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Gastro + Gen Surg > Upper GI Bleeds > Flashcards

Upper GI Bleeds Flashcards

1
Q

What are the 3 main arteries supplying the GIT and what structures do they supply?

A

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

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2
Q

What are the risk factors for upper GI bleeds?

A 
Asparin 
NSAIDs
Warfarin 
Liver disease 
Increased age i.e. increased from with each decade of life 
H. Pylori
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3
Q

Why are upper GI bleeds associated with higher mortality rate compared with lower GI bleeds?

A

Increased risk of damage to artery due to ulcer erosion or oesophageal varices which leads to increased volume or rate of blood loss

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4
Q

Where can a bleed be located to be classified as an upper GI bleed?

A

oesophagus, stomach, duodenum

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5
Q

How might someone with an upper GI bleed present?

A

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

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6
Q

What are melaena not be used to indicate?

A

The severity/degree of bleeding

I.e. only 50ml required for melaena to present

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7
Q

What are the major causes of upper GI bleeds?

A 
Gastric erosions 
Duodenal or gastric ulcers 
Oesophageal varices 
Mallory-Weiss tear 
Cancer 
Oesophagitis 
Dieulafoy’s lesion 
AV malformation 
Aorta-enteric fistula 
Haemobilia
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8
Q

What is haemobilia?

A

Blood in biliary tree which is then refluxed into stomach

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9
Q

Why can oesophagitis result in upper GI bleeding?

A

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

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10
Q

What is Mallory-Weiss Tear? How is it different to Boerhaave’s syndrome?

A

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

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11
Q

Why do oesophageal varices form?

A

Increased portal hypertension leads to back flow of pressure which causes dilatation of oesophageal veins to form varices

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12
Q

What type of duodenal ulcer would you be more concerned about if found during endoscopy?

A

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

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13
Q

Would a stomach ulceration present with bleeding? What are other possible presentations?

A

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

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14
Q

What clinical signs might indicate severe upper GI bleed?

A

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

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15
Q

Why is a fall in Hb not the most sensitive way to assess for upper GI bleed severity?

A

Acute loss can take while to translate into fall int Hb due to it taking time for dilation to occur

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16
Q

What is the different between the Rockhall and Glasgow-Blatchford scoring system?

A

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

17
Q

What are the components used for the Blatchford score? What score indicates high risk of upper GI bleed?

A 
Drop in Hb 
Rise in urea 
Low BP
High HR
Syncope 
Melaena

> 0

18
Q

Why does urea rise in upper GI bleeds?

A

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

19
Q

What are the components of Rockhall scoring system and what are they used to calculate?

A

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

20
Q

What are upper GI bleeds managed?

A

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
21
Q

What types of endoscopic therapy can be used in the case of upper GI bleeds?

A

Adrenaline injection to tamponade and vasoconstrict vessels

Metal clips

Heater probe

Coagulation powder sprays

22
Q

How does pH effect clotting ability of blood? Therefore what drug therapy can be used as an adjunct in upper GI bleeds?

A 
pH<6= pepsin activated which leads to lysing of clot 
pH<5= clotting not affective

IV omeprazole acts to maintain pH for 24hrs

23
Q

What can be done to prepare a patient medically for OGD?

A

Tranexamic acid
Stabilise clots
NBM
Fluids

24
Q

What event can trigger variceal bleeding and what can be done to decrease the risk of this occurring?

A

Bacteraemia

Prophylactic antibiotics

25
Q

Why would patient with variceal bleeding by given Terlipressin?

A

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

26
Q

What is band ligation of varices?

A

Band passes around the neck of varices which encourages clotting in varices and for varices to fall off

27
Q

When is banding not possible? What is the alternative endoscopic therapy for varices?

A

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

28
Q

Why is there a rise in urea with upper GI bleeds? What are the other differentials for raised urea?

A

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
29
Q

What is important to ask as part of HX for PR or haematemesis?

A

Ask if patient on NSAIDs

-risk factor for peptic or gastric ulcers which can lead to bleeding

Gastro + Gen Surg (45 decks)

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