Upper + lower GI bleeding

Question 1

Define haematemesis

Answer 1

vomiting blood

Question 2

Define melaena

Answer 2

blood from upper GI tract passed PR
digested blood
smells bad

Question 3

Define haematochezia

Answer 3

blood from back passage
red

Question 4

Define occult bleeding

Answer 4

hidden blood
people don’t realise they’re passing it

Question 5

Oesophageal arterial anatomy

Answer 5

upper 1/3 = inferior thyroid artery
middle 1/3 = thoracic aorta
lower 1/3 = oesophageal artery (branch of left gastric artery)

Question 6

Oesophageal venous anatomy

Answer 6

upper 2/3 = oesophageal veins to azygous vein to SVC

lower 1/3 = left gastric vein to portal venous system

Question 7

What can happen to the oesophagus when there is portal venous hypertension?

Answer 7

portal pressure >12mmHg = gradient of 10mmHg (comparing portal pressure to IVC pressure)

gradients >10mmHg = blood is redirected to area of lower venous pressure and collaterals form in lower oesophagus

these vessels are thin walled and become more so as they engorge = tendency to bleed

Question 8

Main causes of portal hypertension

Answer 8

liver cirrhosis:
- alcohol
- Hep B + C
- non-alcoholic fatty liver disease
- primary biliary cirrhosis

portal vein thrombosis

congenital

Question 9

What is a Mallory-Weiss tear?

Answer 9

partial thickness mucosal tear of lower oesophagus

typically due to lots of vomiting

Question 10

What is the most common cause of upper GI bleeding?

Answer 10

gastric/duodenal ulcers

Question 11

What can cause gastric/duodenal ulcers?

Answer 11

H pylori
NSAIDs
steroids

Question 12

What is Dieulafoy’s malformation?

Answer 12

large tortuous arteriole in sub mucosa which erodes through
(treated with endoscopic clip)

Question 13

How do gastric neoplasms often present?

Answer 13

anaemia symptoms

Question 14

Management of acute upper GI bleeds

Answer 14

ABCDE
endoscopy (inject with adrenaline, clips)
surgery?

Question 15

What is the most common malformation of the GI tract?

Answer 15

Meckel’s diverticulum - common congenital abnormality of the small intestine caused by incomplete obliteration of the vitelline (omphalomesenteric) duct

Question 16

Investigation + treatment of mesenteric ischaemia/thrombosis

Answer 16

angiography/CT
interventional radiology/vascular surgery

Question 17

Rarer causes of lower GI tract bleeding

Answer 17

Crohn’s
small bowel neoplasms

Question 18

Colonic bleeds causes

Answer 18

diverticular bleeds
angiodysplastic lesions
ulcerative colitis
colonic polyps/malignancy

Question 19

Are diverticular bleeds painful?

Answer 19

no (however diverticulitis is painful)

Question 20

What are angiodysplastic lesions?

Answer 20

degenerative lesions
likely caused by intermittent contraction of colon interrupting venous drainage

Question 21

What is it called when ulcerative colitis is limited to the rectum?

Answer 21

proctitis

Question 22

Arterial supply to the rectum

Answer 22

upper 1/3 = superior rectal artery (branch of inferior mesenteric artery)

middle 1/3 = middle rectal artery (internal iliacs)

lower 1/3 = inferior rectal artery (branch of internal pudendal artery)

Question 23

What is a haemorrhoid?

Answer 23

engorgement of haemorrhoidal cushions
painless (but uncomfortable)
bright red fresh blood
blood on wiping

Question 24

What is an anal fissure?

Answer 24

tear of break in skin of anus
very painful (will not tolerate PR)

Question 25

What causes an aorto-enteric fistula most commonly?

Answer 25

infected prosthetic graft (eg. from AAA repair) eroding through into GI tract

can also happen where no previous repair

life threatening - dealt with by vascular surgeons

Question 26

Define shock

Answer 26

acute circulatory failure with inadequate tissue perfusion causing cellular hypoxia

Question 27

Key history points for GI bleed

Answer 27

differentiate between lower + upper GI bleed

idea about volume of blood lost (patient estimates often inaccurate)

anticoagulant medications

coagulopathies