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GI bleeding Flashcards

1
Q

What signs should be recognised as potential upper GI bleed

A

Haematemesis
Coffee ground vomit
Melana

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2
Q

Resus for upper GI bleed management. When transfuse?

A

NEWS
IV crystalloid
Transfuse if Hb below 70g/L. (aim for 70-100)

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3
Q

What do you use to risk assess an upper GI bleed?

A

Glasgow Blatchford Score

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4
Q

What should you give if sus varices

A

Terlipressin 2mg IV
Antibiotics as trust protocol
Continue aspirin
Suspend other antithrombotics

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5
Q

What investgiation should refer to and when with upper GI bleed?

A

Endoscopy in 24 hours of presentation
GI specialist if require therapeutic endoscopy

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6
Q

When should you activate major haemorrhage protocol and critical care review?

A

Haemodynamic instability

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7
Q

What landmark sperates upper and lower sources of GI bleeding?

A

Ligament of Treitz (suspensory ligament of the duodenum, suspends the duodejejunal flexure form the retroperitoneum)

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8
Q

How does bleeding above vs below the ligament of Treitz present?

A

Above -> haematemesis or melana
Below -> haematachazia (passing blood)

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9
Q

What is melaena?

A

Dark, black and tarry stool
Strong odour - digestion of haemoglobin

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10
Q

How to differentiate between iron induced black stool and melaena?

A

Iron will have a green tinge when spread thinner, melaena wont

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11
Q

Common causes of upper GI bleed list

A

Gastric and/or duodenal ulcers
Severe or erosive gastritis/duodenitis
Severe or erosive esophagitis
Esophagogastric varices
Portal hypertensive gastropathy
Angiodysplasia (also known as vascular ectasia)
Mallory-Weiss syndrome
Mass lesions (polyps/cancers)
No lesion identified (10 to 15 percent of patients)

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12
Q

Symptoms of Mallory Weiss syndrome

A
  • Emesis
  • Retching
  • Coughing prior to haematemesis
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13
Q

Signs that indicate variceal bleed

A

jaundice
Ascites

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14
Q

Which peptic ulcer pain is relieved by eating?

A

Duodenal

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15
Q

Why is duodenal ulcer pain relieved by food?

A

Presence of food in the stomach triggers release of digestive juices which are alkaline and relieve the acidic pH

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16
Q

If the patient complains of pain when they eat which ulcer is it more likely t be?

A

Gastric

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17
Q

Symptoms peptic ulcer

A

Dyspepsia
Central burning chest pain

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18
Q

Signs of malignancy causing upper GI bleed

A
  • Dysphagia
  • early satiety
  • Cachexia
  • Involuntary weight loss
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19
Q

When is haematachezia seen with an upper GI bleed

A

When the bleed is massive

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20
Q

Why can upper GI bleeds be associated with orthostatic hypotension

A

When they are big enough to cause haemodynamic instability

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21
Q

History questions ass symptoms with upper GI bleed

A

painless vs. painful
trouble swallowing
unintentional weight loss
preceding emesis or retching
change in bowel habits

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22
Q

Symptoms of an oesophageal ulcer

A

Odynophagia, GORD, dysphagia

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23
Q

What is important to consider in a patient with a history of AAA or aortic graft with an upper GI bleed?

A

Aorto-eneteric fistula - abnormal connection between the aorta and the blood supply to the GI tract

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24
Q

What is angiodysplasia and how diagnosed

A

an abnormal, tortuous, dilated small blood vessel in the mucosal and submucosal layers of the GI tract.
Diagnosed with colonoscopy or angiography

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25
Q

What PMH is important when considering an angiodysplasia?

A

Renal disease
Aortic stenosis
Hereditary haemorrhagic telangiectasia

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26
Q

What are risk factors for peptic ulcer diseas?

A

H.pylori infection
Smoking
NSAID use
Antithrombotic use

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27
Q

What should you especially consider if H.pylori infection, exccess alcohol and smoking are in the history?

A

Malignancy
Peptic ulcer disease

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28
Q

What could cause upper GI bleed in a patient with gastroenteric anastomosis

A

Marginal ulcers - ulcers at an anastomic site

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29
Q

What conditions can cause overload in rigorous fluid resus?

A

CKD, HF

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30
Q

What patients is anaemia especially dangerous in?

A

IHD

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31
Q

What to assess for in exam for upper GI bleed

A

Full A to E if acute
Hypovolaemia
Resting tachycardia
Orthostatic hypotnesion
Supine hypotnesion
Signs of liver disease

PR exam
-anal fissures
Haemorrhoids
Anorectal mass
Stool exam

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32
Q

Which bloods ask for in upper GI bleed?

A

FBC
G+S
INR, PT, APTT
Lactate
LFTs
Renal function - U+Es
Urea may be elevated
CRP
B12/folate/ferritin

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33
Q

Why is urea sometimes eleated in upper GI bleed?

A

Proteins in blood absorbed in GI tract and transported to kidney - increased waste product

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34
Q

What does a low MCV suggest about the casue of a bleed?

A

Iron deficiency anaemia, chronic bleeding

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35
Q

Differentials for an upper GI bleed

A

Peptic ulcer disease
GE varices
Upper GI cancers - oesophageal, gastric
Erosive oesophagitis/gastritis/duodenitis
Mallory Weiss tear

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36
Q

Causes of haemotachezia

A

Diverticulitis
Colitis: -IBD - Crohns, UC. -Ishcaemic -Infective, C.difficile
Colorectal cancers
Haemorrhoids
Anal fissure

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37
Q

What ass symptoms should you ask about with a GI bleed?

A

Pain
GI Upset
Nausea/vomiting
Diarrhoea
Constipation
Mucus in stool
Pale stool
Malaena (indicating UGI bleed, which has been digested and excreted, of sufficient volume to alter stool composition)
Dark urine - indicating possible obstructive jaundice
Water brash
Dysphagia
Dyspepsia (ALARMS symptoms)
Reduced appetite
Weight loss
Flatus
Bloating
Tenesmus
Early satiety
Perianal itch.

38
Q

What diagnosis would be most likely in a young patient with diarrhoea, mucus in stool ad haematochezia?

A

IBD
Get travel history

39
Q

What diagnosis would be most likely in a older patient with L iliac fossa pain and haemotachezia?

A

Diverticulitis

40
Q

What sort of vimtting is seen in a Mallory-Weiss tear?

A

Profuse with no blood initially then streaks of fresh blood

41
Q

What does jaundice and haematemesis signal?

A

Oesophageal varices rupotured

42
Q

What diagnosis does dyspepsia nad coffee ground vomit suggest?

A

Peptic ulcer disease

43
Q

What symptoms make infective colitis/dysentry like;ly?

A

Fevers, bloating, acute D/V, unusualy food and heamatochezia, recent travel

44
Q

Main symptoms of haemorrhoids

A

Tenesmus, perianal itch and constipation with heamatochezia

45
Q

What is proctalgia?

A

Pain around anus/rectum

46
Q

What symptoms make an anal fissure more likely?

A

Constipation
Blood on wiping after passing stoll
Proctalgia

47
Q

What bacteria may be implicated in haemolytic uraemic syndrome?

A

E.Coli O157

48
Q

What orgnaism is teh most common cause of bloody diarrhorea?

A

Shigella dysentriae

49
Q

What is the most common cause of gastroenteritis?

A

Norovirus. Blood noy normally present

50
Q

What does Shigella dysentriae cause?

A

Severe inflammation and necrosis in colon epithelium

51
Q

What is Giardia Lamblia?

A

Parasitic infection causing malabsorption, abdominal pain, bloating and diarrhoea with steatorrhea

52
Q

What are large volume GI bleeds more likely to be?

A

varices, peptic ulcer disease, diverticulitis, colitis.

53
Q

What does H.pylori increase your risk of?

A

Peptic ulcer disease
Gastic cnacer

54
Q

Why are IBD patients at a higher risk of cancer

A

Chronic intestinal inflammation
Immunosupression

55
Q

Why is pain worse at night and can wake patients with a duodenal ulcer up?

A

When the stomach is empty there are continour secretions moving through to the duodenum -> irritate ulcered area

56
Q

What is alendronate

A

A Bisphosphonate

57
Q

Which inherited condition increases the risk of a variety of cnacers?

A

HNPCC hereditary non polyposis colorectal cancer

58
Q

Why do polyunsaturated fats increase you risk of cancer?

A

Increased cholesterol secretions which are broken down into potential carcinogens in GI tract

59
Q

WHich GI conditions does smoking increase the risk of?

A

PUD
GI cancer
Flares of Crohns

60
Q

Steps to manage an acute upper GI bleed

A

1) Stabilise the patient (fluid resusitation, transfusions, reversal of anticoagulation, Terlipressin)

2) Risk stratification based on Rockall and Blatchford Scoring systems

3) Endoscopic management in due course

61
Q

What score is used to assess upper GI bleeding?

A

Rockall score

62
Q

Features of the rockall socre

A

Age, shock, comorbidity, diagnosis (eg MW tear = o, GI malignancy - 2)
Evidence of bleeding

63
Q

What score strratifies high and low risk upper GI bleeds?

A

Glasgow-Blatchford bleeding score. Any risk higher than 0 needs intervention

64
Q

Management of acute upper GI bleed

A

https://www.nice.org.uk/guidance/cg141/resources/acute-upper-gastrointestinal-bleeding-in-over-16s-management-pdf-35109565796293
Make more flash cards off NICE guidance

65
Q

What GI condition can CVS issues predispose to?

A

Ischaemic colitis

66
Q

How does ischaemic colitis cause metabolic acidosis?

A

Raises lactate levels

67
Q

Evidence of diverticulits on CT

A

Thickening of bowel wall
Enhancement of colonic wall
Dark spot at centre=diverticula

68
Q

GI bleed symptoms to ask

A
  • Pain
  • GI Upset
    • Nausea/vomiting
    • Diarrhoea
    • Constipation
    • Mucus in stool
    • Pale stool
    • Malaena
  • Dark urine - indicating possible obstructive jaundice
  • Water brash
  • Dysphagia
  • Dyspepsia (ALARMS symptoms)
  • Reduced appetite
  • Weight loss
  • Flatus
  • Bloating
  • Tenesmus
  • Early satiety
  • Perianal itch.
69
Q

Most common cause of bloody diarrhoea?

A

Shigella dysentriae

70
Q

Initial management GI bleed

A

Ensure good IV access - 2 green venflows minimum

71
Q

Criteria for central line insertion

A

Severe shock
Rebleeding
Severe comorbidity ehere CVP monitoring adventageous eg cardiac or renal failure
Difficult/poor peripheral access

72
Q

What Rockall score is mod to severe risk?

A

3-7

73
Q

What rockall score is mild to mod risk?

A

0 -2

74
Q

Factors Rockall score

A

Age - <60, 60-79, >79
Stigmata of shock - tachy, hypotension <100
Co-morbidity - IHD/CVA/COPD, renal/liver failure, disseminated mailgnancy

75
Q

What is the Glasgow blathcford score?

A

For bleeding
Blood urea
Haemoglobin for men or women
other markers =
pulse, melaena, syncope, hepatic disease, cardiac failure

76
Q

Initial management diarrhoea, tachycardic, bleeding, on warfarin

A

IV fluid bolus then maintenance
Reveres patients wararin with vit K
Start on broad specturm antibioitcs
Adequate analgesia - NOT NSAIDs
Disscuss with surgical registrat on call

77
Q

Bleeding disorders family history

A

Von Willebrands disease
Haemophilia A
Factor V leiden
Antiphospholipid syndrome

78
Q

Hereditary family bowel conditions

A

Herediatry non-polyposis colorectal cancer
Familial adenomatous polyposis

79
Q

What drugs can cause GI bleed?

A

Bisphosphonates - inflammation, ulcers, strictures, gastritis, upper GI blees
Anticoagulation - reverse
NSAIDs
Sreroids - risk of ulcers
PPIs/H2 receptor anatagonists - protective, suggests prev problme

80
Q

Important PMH for bleeding CUSHINGPID

A

C – Cataracts
U – Ulcers
S – Striae, Skin thinning
H – Hypertension, Hirsutism
I – Immunosuppression, Infections
N – Necrosis of femoral heads
G – Glucose elevation
O – Osteoporosis, Obesity
I – Impaired wound healing
D – Depression/mood changes

81
Q

What does melaena indicate

A

(indicatingUGI bleed, which has been digested and excreted,of sufficient volume to alter stool composition)

82
Q

When are red cells considered in a resus situation?

A

When 30% of circulating volume lost

83
Q

When do yuo give fresh frozen plasma in a bleed?

A

Fibrinogen <1g/L
or
PT/INR ir APTT >1.5 x normal

84
Q

When give platelets in resus

A

If actively bleeding and platelets under 50 x109/L

85
Q

What do you give to ppl on warfarin who are actively bleeding?

A

Prothrombin complex concentrate

86
Q

Variceal bleed treatements

A

oesophageal = band ligation
Gastric - N-butyl-2-cryanoacrylate for gastric varices
Transjugular intrahepatic portosystemic shints - TIPS offered if bleeding uncontrolled from above

87
Q

Causes of upper GI bleed

A

Peptic ulcer
Mucosal inflammation - oeoph, gast, duodenitis
Oesophageal varices
Mallory weiss tear
Gastric carcinoma
Coagulation disorders eg thrombocytopenia, warfarin

88
Q

What do subcutaneous emphysema and vomitting suggest?

A

Oesophageal perfoartion - Boerhaave syndrome

89
Q

What score do you use at first assessment vs endoscopy for upper GI bleed?

A

Blatchford - 1st assess
Rockall score - endoscipy after

90
Q

What tdoes the Blatchford score calculate?

A

Higher scores (0-23) correspond with increased acuity and mortality

91
Q

Admission risk markers counted in Baltchford score

A

Blood urea
Hb men or women
Systolic BP
Other markers - pulse, melaena, syncope, hepatic disease, HF

gi, liver, kidney (50 decks)

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