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GI > W3 Acute Upper GI Haemorrhage > Flashcards

W3 Acute Upper GI Haemorrhage Flashcards

1
Q

List most common 5 causes of an acute upper GI bleed.

A
  • duodenal ulcer
  • gastric erosions
  • gastric ulcer
  • varices
  • Mallory-Weiss tear
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2
Q

List 5 rarer causes of acute upper GI bleed.

A
  • oesophagitis
  • erosive duodenitis
  • neoplasm
  • stomal ulcer
  • oesphageal ulcer
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3
Q

What tends to cause a Mallory-Weiss tear?

A

Excessive vomiting or coughing

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4
Q

What is the “100 rule”?

A
  • it signifies poor prognostics
  • systolic BP <100mmHg
  • pulse >100/min
  • Hb <100 g/l
  • age >60
  • comorbid disease
  • postural drop in bp
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5
Q

What response is poor in diabetics?

A

autonomic response

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6
Q

What is purpose of endoscopy for acute upper GI bleed?

A
  • identify cause
  • therapeutic manoeuvres
  • assess risk of rebleeding
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7
Q

What does the Rockall Risk scoring system assess?

A

-mortality risk of patient with acute upper GI bleed

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8
Q

What does Rockall Risk scoring system score based on?

A
  • age
  • pulse
  • systolic BP
  • co-morbidity
  • diagnosis
  • stigmata
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9
Q

What is immediate treatment for patient with acute upper GI bleed?

A
  • resuscitation: ABC (airway, breathing, circulation)
  • airway protection
  • oxygen
  • IV access
  • fluids
  • then endoscopy
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10
Q

What does the Blatchford Score assess?

A

The likelihood of a patient with an UGIB needing medical intervention (endoscopy/blood transfusion) and need to stay in hospital.

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11
Q

What does the Blatchford Score score on?

A
  • blood urea
  • hb levels
  • systolic bp
  • Other:
  • pulse
  • presentation with melaena
  • presentation with sycnope
  • hepatic disease
  • cardiac failure
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12
Q

What PPI is recommended for acid suppression in patient with acute UGIB?

A

-IV omeprazole

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13
Q

What drug is administered if stigmata of cirrhosis/known liver disease to patient with UGIB?

A

-terlipressin

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14
Q

Why administer omeprazole in upper GI bleed?

A

-helps facilitate platelet aggregation cos creates a neutral pH

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15
Q

What are indications for blood transfusion?

A
  • Shock (pallor, cold nose, systolic BP <100, pulse >100)

- Hb <100g/l in patients with recent/active bleeding

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16
Q

Why always large-bore IV cannulae in acute UGIB?

A

To be able to restore lost blood volume with saline/blood transfusion.

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17
Q

What are 3 stigmata of recent haemorrhage during endoscopy?

A
  • active bleeding/oozing
  • overlying clot
  • visible vessel
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18
Q

How can patients with acute upper GI bleed present?

A
  • malaena
  • haematemesis
  • patients are sometimes haemodynamically unstable when large bleed and in shock
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19
Q

List 5 types of endoscopic treatment of peptic ulcers bleed.

A
  1. adrenaline injection
  2. heater probe coagulation
  3. combinations of injection and heater probe coagulation
  4. clips
  5. haemospray
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20
Q

What are potential causes of clot dissolution in an ulcer bleed?

A
  • acid in lumen
  • pepsin in lumen
  • fibrinolysins in blood stream (e.g. drugs)
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21
Q

What should always be checked in patient with acute UGIB due to peptic ulcer?

A
  • presence of H.pylori bacteria

- prevention of infection

22
Q

How does haemospray work?

A
  • Haemospray sprayed over open wound
  • when it comes in contact with blood the powder absorbs water and forms a cohesive, adhesive mechanical barrier over the bleed
23
Q

Why is adrenaline injection used to slow/stop bleeding?

A

Because its acts as a vasoconstrictor and reduces blood flow in that area

24
Q

What are risk factors of acute variceal bleeding?

A
  • portal pressure >12mmHg
  • varices >25% oesophageal lumen
  • degree of liver failure
25
Q

Why does acute variceal bleeding have such a high mortality rate of 25-50%?

A

Due to complications e.g. sepsis, liver failure

26
Q

What is portal hypertension commonly caused by?

A

cirrhosis

27
Q

How can portal hypertension cause oesphageal varices and name the exact veins?

A
  • Blood flow through portal vein can be diverted due to the high pressure and flow back through anastomoses between portal venous system and systemic venous system.
  • In oesophageal varices, blood can flow back through the left gastric vein and through the oesophageal veins and drain into the azygous vein
  • the periesophageal venous plexus veins are not designed for that high pressure and so can become tortuous and dilate
28
Q

What findings when taking patient history would make you suspicious of varices in a bleeder?

A
  • chronic alcohol excess
  • chronic viral hepatitis infection
  • metabolic or autoimmune liver disease
  • intra-abdominal sepsis/surgery
  • cirrhosis with varices
29
Q

List 6 clinical signs of liver disease, in particular alcoholic cirrhosis.

A
  • spider naevi
  • leukonychia
  • palmar erythema
  • ascites
  • jaundice
  • encephalopathy
30
Q

What is encephalopathy?

A

Brain disease/malfunction

31
Q

What are the aims of management of variceal bleeding?

A
  • resuscitation
  • haemostasis
  • prevent complications of bleeding
  • prevent deterioration of liver function
  • prevent early re-bleeding
32
Q

List 5 mechanisms to achieve haemostasis in acute variceal bleeding.

A
  • terlipressin
  • endoscopic variceal ligation (banding)
  • sclerotherapy
  • sengstaken-blakemore balloon
  • TIPS
33
Q

What is sclerotherapy?

A

Injection of agent into blood vessel or lymph vessel that causes it to shrink

34
Q

What is terlipressin?

A

vasopressin prodrug

35
Q

What is a prodrug and why are they useful?

A
  • A biologically inactive compound that is metabolised into an active drug when administered into the body
  • improves bioavailability of drugs that are poorly absorbed from GI tract
36
Q

What class of drug is vasopressin?

A

Antidiuretic

37
Q

In what vessels does terlipressin predominantly induce vasoconstriction?

A

splanchnic vessels

38
Q

How is Sengstaken-Blakemore Tube used?

A

SB tube is inserted into nose/mouth down into oesphagus and stomach and balloons are inflated to put pressure on bleeding varices and stop bleeding

39
Q

When is Sengstaken-Blakemore Tube used?

A

When endoscopic haemostasis treatment fails

40
Q

What is the TIPS procedure?

A
  • Transjugular Intrahepatic Portosystemic Shunt
  • shunt placed between portal vein and hepatic vein to treat portal hypertension and uncontrollable gastric variceal bleeding
41
Q

When bleed stops what is treatment for oesophageal varices?

A

Propranolol and a banding programme

42
Q

What does parenteral mean?

A

Administered into the body not through the mouth or alimentary canal

43
Q

What should be considered to be administered in acute variceal bleeding?

A
  • CVP monitoring (portal pressure vs CVP)
  • coagulopathy -> maybe administer Fresh frozen plasma/platelets/vitamin K
  • parenteral vitamins
  • hypoglycaemia
  • replace K+, Mg2+, PO4 2-
  • antibiotics
  • unexpected pathology e.g. DU
  • delirium tremens
44
Q

What is initial endoscopic therapy treatment in acute peptic ulcer bleed?

A
  • adrenaline injection
  • or heater probe thermo-coagulation
  • or clips
45
Q

What is treatment plan of acute peptic ulcer bleed if bleeding stops after endoscopic treatment?

A
  • omeprazole 80mg iv + 8mg/hr/72hrs iv

- H.pylori eradication and course of oral PPI

46
Q

What is treatment plan of acute peptic ulcer bleed if bleeding doesn’t stop after endoscopic treatment?

A

-surgery

47
Q

What is treatment plan of acute peptic ulcer bleed if there is a re-bleed after haemostasis by endoscopic treatment is achieved?

A
  • omeprazole 80mg iv + 8mg/hr/72hrs iv
  • another attempt of endoscopic therapy
  • if unsuccessful then surgery
48
Q

What is initial treatment in acute oesophageal variceal bleed?

A
  • resuscitation
  • antibiotics
  • terlipressin
  • OGD +/- EVL
49
Q

What is treatment plan of acute oesophageal varices bleed if bleed stops after initial treatment?

A
  • propranolol

- banding programme

50
Q

Why are non-selective beta blockers used in treatment of portal hypertension?

A
  • By blocking beta-1 receptors in the heart cardiac output is decreased which decreases portal blood flow
  • By blocking beta-2 receptors there is splanchnic vasoconstriction due to unopposed alpha-adrenergic activity on the vessels thus reducing portal blood flow
51
Q

What is treatment plan of acute oesophageal varices bleed if bleed continues after initial treatment?

A
  • EVL or SB tube

- if unsuccessful then TIPSS

GI (29 decks)

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