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Surgery- UGIT > Upper GIT bleeding and GORD > Flashcards

Upper GIT bleeding and GORD Flashcards

1
Q

Where does most bleeding originate?

A

85% of GI bleeding happens in the UGIT

Proximal to;the ligament of Treitz.

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2
Q

More than 85% of bleeding stops spontaneously, and are a result of 4 pathologies. What are these pathologies?

A 
Peptic ulcers 
Oesophageal varices
Colonic diverticulosis 
  - Diverticulosis:  inflamed pouches in the lining of your intestine
Angiodysplasia
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3
Q

Define hematoemesis:

A

This is a condition in which a patient is found to be vomiting blood.
This could be:
- Digested blood in the stomach (coffee ground emesis = slow bleeding)
- Fresh unaltered blood: (gross blood and clots indicating rapid bleeding)

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4
Q

Define melena:

A

This is a condition in which faeces are dark and sticky, containing partly digested blood, as a result of internal bleeding. Indicates blood has been in the GI for more than 14 hours.
The more proximal the bleeding site, the more likely melena will occur.

Presentaton:
- black,tarry, semi solid and distinct odor.

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5
Q

Define Hematochezia:

A

Hematochezia is the passage of fresh blood through the anus, usually in or with stools (contrast with melena)

Hematochezia is commonly associated with lower gastrointestinal bleeding, but may also occur from a brisk upper gastrointestinal bleed.

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6
Q

What are the examination requirements for upper GIT bleeding?

A
  1. General examinations and systemic examinations
  2. Pulse
    - Thready pulse
  3. Blood pressure
    - Orthostatic hypotension
  4. Signs of shock
    - Cold, clammy, cyanotic, tachycardia, hypotension, chest pain, confusion,
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7
Q

How does a nasogastric lavage work in the diagnosis of bleeding UGIT?

A

A flexible tube is inserted through the nose (goes in via nose to reduce patients likelihood to vomit)
Gastric contents is aspirated and assessed

Used to confirm recent UGITB

  • Coffee ground appearance = recent bleeding
  • Red blood in the aspirate that doesn’t clear = Active bleeding.
  • Lack of blood = Probs isn’t active bleeding but UGITB isn’t excluded
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8
Q

Which 2 lab diagnosis procedures are used in UGITB?

A

CBC with platelet count

  • A complete blood count to asses blood loss
  • Should be taken frequently throughout the day

Hemoglobin value, type and crossmatch blood

  • Hemoglobin should be checked and crossmatched
  • Based on the rate of blood loss
  • Hb level should be monitored serially to asses trends.
  • Unstable trend could mean ongoing haemorrhage requiring intervention.
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9
Q

What are the 3 priorities of bleeding management?

A
  1. Stabilize the patient: protect airway and restore circulation
  2. Identify the source of bleeding
  3. Definitive treatment for the cause
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10
Q

What are 4 points of resuscitation and initial management?

A
  1. Protect airway and position the patient on the side
  2. IV access: use 1-2 bore cannula
  3. Take blood for: Hb, PCV, PT and cross match
  4. Restore circulation
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11
Q

What are the common causes of UGI bleeding?

A

Peptic ulcers
Varices
Mallory-Weiss

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12
Q

What are less common causes for UGI bleeding?

A 
Dieulafoy’s lesions 
Vascular ectasia 
Watermelon stomach 
Gastric varices 
Neoplasia
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13
Q

What are rare causes for UGI bleeding?

A 
Esophageal ulcer
Erosive duodenitis 
Hemobilia 
Crohn’s disease. 
Aorta-enteric fistula
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14
Q

What is the single most common cause of bleeding?

A

Peptic ulcers

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15
Q

What is the cause of peptic ulcers bleeding?

A

Acid erosion into the submucosal or extraluminal blood vessels

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16
Q

What is the danger of duodenal ulcer formation?

A

Duodenal ulcers can erode into branches of the gastroduodenal artery.

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17
Q

Forrests classification of PU bleeding:

  1. What characteristic is associated with stage Ia?
  2. What is the percentage likelihood of rebleeding?
A
  1. Jet arterial bleeding

2. 90% chance of rebleeding

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18
Q

Forrests classification of PU bleeding:

  1. What characteristic is associated with stage Ib?
  2. What is the percentage likelihood of rebleeding?
A
  1. Oozing

2. 50%

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19
Q

Forrests classification of PU bleeding:

  1. What characteristic is associated with stage IIa?
  2. What is the percentage likelihood of rebleeding?
A
  1. Visible vessel

2. 25-30%

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20
Q

Forrests classification of PU bleeding:

  1. What characteristic is associated with stage IIb?
  2. What is the percentage likelihood of rebleeding?
A
  1. Adherent clot

2. 10-20%

21
Q

Forrests classification of PU bleeding:

  1. What characteristic is associated with stage IIc?
  2. What is the percentage likelihood of rebleeding?
A
  1. Black spot in ulcer crater

2. 7-10%

22
Q

Forrests classification of PU bleeding:

  1. What characteristic is associated with stage III?
  2. What is the percentage likelihood of rebleeding?
A
  1. Clean base ulcer

2. 3-5%

23
Q

What is the pharmacological treatment of a bleeding peptic ulcer?

A

PPI 80mg IV bolus
Or
8mg per hour for 72 hours via IV infusion

24
Q

What is the endoscopic treatment of a bleeding peptic ulcer?

A 
Injection of epinephrine 
Mono polar coagulation
Bipolar coagulation
Heater probe 
Hemoclips
Argon plasma coagulation
25
Q

What is the surgical treatment of a bleeding peptic ulcer?

A

Used when endoscopic treatment fails

- under-running.

26
Q

What is under running in peptic ulcers surgery?

A

This laparoscopic procedure involves making a 11mm port just under the xiphisternum. 2 to 3 stitches are passed deep into the ulcer and the sutures are tied tight to stop the bleeding.

27
Q

What is the method of choice for a UGITB?

A

Endoscopy.

28
Q

When should endoscopic therapy be scheduled?

A

For cases with lesions that are actively bleeding
Non-bleeding visible vessels
To ulcers with an adherent blood clot

29
Q

When shouldn’t endoscopic therapy be scheduled, due to excellent prognosis of the type of peptic ulcer being formed?

A
  • Black or red spots
    • A clean ulcer base with oozing
      Do not require endoscopic intervention since these lesions have an excellent prognosis without intervention.
30
Q

True or false: Adrenaline should not be used as monotherapy for the endoscopic treatment of non-variceal UGIB

A

True:

Adrenaline should not be used as mono-therapy for the endoscopic treatment of non-variceal UGIB

31
Q

Give 3 treatment options for the treatment of Non-variceal bleeding:

A
  1. Mechanical method- I.e. Clips with or without epinephrine
  2. Thermal coagulation with epinephrine
  3. Fibrin or Thrombrin with adrenaline
32
Q

When Should radiology be offered as a treatment method?

A

In unstable patients who rebleed after endoscopic treatment.
Should radiology fail to work, refer patient for surgery

33
Q

What are 5 conditions that qualify a patient for surgery

A
  1. Persistent hypotension
  2. Failure of medical or endoscopic treatment
  3. Coexisting condition i.e. perforation, obstruction, malignancy
  4. If transfusion is required
  5. Recurrent hospitalization.
34
Q

What are 3 types of operations?

Note these are dependent on the site and bleeding lesions.

A
  1. Duodenal ulcers are treated by under running with/without pyloro-plasty.
  2. Gastric ulcers are treated by under running
    • A biopsy should be taken too, to exclude carcinoma
  3. Local excision or partial gastrectomy will be required.
35
Q

What medication is issued for variceal bleeding?

A
  1. Terlipressin
    Should be stopped:
    - Once definitive homeostasis is reached right.
    - Or after 5 days unless it is needed for something else.
  2. Prophylactic Antibiotic therapy
  3. Balloon tamponade should be considered as a temporary salvage treatment for uncontrolled variceal haemorrhage
36
Q

What 3 treatment procedures are used for bleeding oesophageal varices?

A
  1. Band ligation
  2. Stent insertion
  3. Trans-jugular intrahepatic portosystemic shunts (TIPS) should be considered if band ligation for bleeding oesophageal varices does not work.
37
Q

What 3 treatment procedures are used for bleeding gastric varices?

A
  1. Endoscopic injection of N-butyl-2-cyanoacrylate

2. Trans-jugular intrahepatic portosystemic shunts (TIPS) should be offered if N-butyl-2cyanoacrylate does not work.

38
Q

When does GORD occur?

A
  1. Functional dyspepsia (Indigestion)
  2. Defense mechanism failure :- hernia or overload
  3. Mucosal hypersensitivity
39
Q

Name the 3 divisions of GORD:

A
  1. Erosive GORD
  2. Non-erosive GORD
    • True GORD
    • Hypersensitive oesophagus
    • Functional heartburn
  3. Refractory reflux
40
Q

Symptoms of a GORD can be divided into:
Typical/Atypical Oesophageal/Extra-oesophageal symptoms
Name 2 Typical oesophageal symptoms of GORD

A
  1. Heart burn
    • Burning sensation in the retro-sternal space
  2. Regurgitation
    • Refluxed gastric contest into the mouth or hypopharynx.
41
Q

Should a GORD diagnosis be made when a patient presents with typical or atypical oesophageal symptoms?

A

Patient must present with typical oesophageal symptoms in order for GORD to be diagnosed.
- Do not diagnose GORD if pt. Presents with atypical symptoms.

42
Q

Name 4 atypical oesophageal symptoms of GORD:

A

Hiccups
Sleep disturbances
Epigastric pain
Non-cardiac chest pain

43
Q

Name a few extra-oesophageal symptoms of GORD:

A 
PULMONARY FIBROSIS
Asthma 
Constant coughing
Chronic laryngitis 
Sinusitis 
Pharyngitis 
Recurrent otitis media
44
Q

What factors exacerbate the likelihood of GORD development:

A 
Pregnancy 
Obesity 
Age 
Genetics 
Trauma 
Smoking 
Neuromuscular dysfunction
45
Q

What are the alarm symptoms for a patient that might need to undergo endoscopic treatment?

A 
Dysphagia 
Weight loss 
Upper GI bleeding 
Anaemia 
Chronic symptoms 
Elderly
46
Q

What is the gold standard for GORD diagnosis?

A

24 hour ambulatory PH and impedance monitoring

- Helps to determine the type of reflux disease.

47
Q

What are the treatment management choices for GORD?

A 
PPI 
Diet and lifestyle changes 
Pro-kinetics 
Medication: Baclofan
Anti-reflux surgery
48
Q

What complications are associated with GORD?

A

Bed in strictures
Barrett’s Oesophagus
Adenocarcinoma
Pulmonary disease -: Fibrosis

Surgery- UGIT (9 decks)

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