Upper GIT haemorrhage Flashcards

1
Q

Causes of acute upper GIT haemorrhage

A
  • Oesophagus: Oesophageal varices, Mallory-Weiss tear
  • Stomach: Gastric ulcer, erosive haemorrhagic gastritis
  • Duodenum: Duodenal ulcer, erosive duodenitis
  • Other uncommon causes: tumours, stomal or anastomotic ulcers, vascular malformation, oesophagitis or oesophageal ulcers
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2
Q

Typical history of peptic ulcer disease

A

History of periodic dyspepsia related to meals or excessive analgesic ingestion (Not sensitive or specific)

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3
Q

History given for a mallory-weiss tear

A

History of an episode of repeated vomiting

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4
Q

In a patient with excessive alcohol intake and known liver disease, what is the likely cause of upper GIT bleeding

A

oesphageal varices

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5
Q

What is maelena and what does it indicate

A
  • Black tarry stools which is formed by blood mixed with acid
  • Indicates that the source of bleeding is in the upper GIT tract
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6
Q

In severely shocked patients, what should be mandatory

A
  • Central venous pressure line and urinary catheter
  • Baseline haematolological and biochemical investigations must be urgently requested together with cross-matching of blood
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7
Q

How is the resuscitation of patients with suspected liver disease different to other patients with upper GIT bleed

A

Patients with underlying liver disease should not be given sodium containing crystalloid solutions. They should be resuscitated only with blood, 5% dextrose, given fresh frozen plasma to replenish clotting factors and receive ocreotide to lower portal pressure

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8
Q

Uses and disadvantages of use of nasogastric tube in patients with upper GIT haemorrhage

A
  • Uses: Early identification of recurrent or continued bleeding, the performance of gastric lavage and emptying the stomach contents before endoscopy
  • Disadvantages: Unreliable in detecting rebleeding, uncomfortable for the patient, may cause rather than prevent aspiration in the elderly patients
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9
Q

Diagnostic procedure of choice for upper GI bleeding

A

Endoscopy

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10
Q

When is urgent endoscopy indicated

A

-Oesophageal varices are suspected or where there are signs of continuing haemorrhage. High risk patients should undergo endoscopy as soon as they are stabilised

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11
Q

If an urgent endoscopy is not indicated, when should it be performed

A

-Where urgent endoscopy is not indicated, patients should undergo a full diagnostic endoscopy within 12-24 hours of admission when they are clinically stable and have been fully resuscitated

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12
Q

Forrest classification of peptic ulcers (High risk)

A
  • IA: Spurting blood (visible vessel)
  • IB: ooze blood (non-visible vessel)
  • IIA: non bleeding visible vessel
  • IIB: Adherent clot
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13
Q

Forrest classification of peptic ulcer (low risk)

A

IIC: pigmented spot
III: clean ulcer base

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14
Q

When is angiography indicated

A

Indicated in number of patients who continue to bleed and when endoscopy has failed to disclose a likely bleeding site. Bleeding from obscure and uncommon sites such as the liver, pancreatic duct, small bowel and colon may be identified.

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15
Q

What risk stratification score is used in patients with upper GIT bleeding, what score indicates increased risk of bleeding and death

A
  • Rockall risk score

- A total score of over two indicates increased risk of bleeding and death

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16
Q

Parameters measured in the Rockall risk score

A
  • Age
  • Haemodynamic status
  • Co-morbidities
  • Endoscopic diagnosis
  • Stigmata of recent haemorrhage
17
Q

When treating bleeding peptic ulcers, what is the goal of medical therapy

A

Increase the intragastric pH to above 6

18
Q

Initial management of bleeding peptic ulcer

A
  • Assess haemodynamic status
  • Obtain FBC, U and E, INR
  • Commence resuscitation
  • Consider IV PPI
  • Perform endoscopy
19
Q

Patients at risk for rebleeding of peptic ulcer

A
  • Age over 60
  • Shock on admission
  • Endoscopic stigmata of recent bleeding
  • Large ulcers (>2 cm)
  • Lesser curve gastric and posterior duodenal bulb ulcers
20
Q

How long should high risk patients be obeserved in the hospital for following bleeding peptic ulcer

A

minimum of three days

21
Q

endoscopic therapy for bleeding peptic ulcer

A
  • Injections with diluted adrenalin (1: 10 000)

- Bipolar thermal coagulation

22
Q

Who should angiography and embolisation be reserved for in bleeding peptic ulcer disease

A

-patients who failed endoscopic treatments and are poor candidates for surgery

23
Q

Indications for surgery in bleeding peptic ulcer disease

A
  • Exanguinating haemorrhage
  • Associated perforation
  • Failed endoscopic therapy of active bleeding in shocked patients
  • Recurrent bleeding after endoscopic therapy
  • Patients at risk for rebleeding where endoscopic therapy is not available
24
Q

management of high risk patients with bleeding peptic ulcer disease

A
  • Admit to high care unit
  • Endoscopic therapy
  • Commence IV PPIs
  • initiate oral intake of clear fluids 6 hours after endoscopic haemostastis
  • transition to oral PPIs
  • perform testing for H. pylori, initiate eradiacation therapy if result is possible
25
Q

Management of low risk patients with bleeding peptic ulcer disease

A
  • No endoscopic haemostasis
  • commence oral PPI
  • Perform testing for H. Pylori
  • Initiate eradication therapy if result is positive
  • Consider early discharge from hospital