GI Bleeds - Upper and Lower Flashcards
What separates the Foregut from the hindgut? What is another name for it?
Ligament of Trietz or DJ flexure
The ligament of Trietz lies on the second part of the duodenum. In Pediatrics and neonatology, what surgical emergency would be this be involved in? Explain.
Volvulus due to the malrotation of the small bowel. It is normally located on the left side but if malrotated, it will be present on the right side (this is the diagnosis of it too)
The ligament of Trietz is highly vascularized receiving supply from the oesophageal arteries from the thoracic aorta, the celiac trunk, and the porto-systemic venous anastomosis. One of these blood supplies are greatly involved in PUD. State the branches of the blood supply most involved in PUD?
Celiac trunk branches into the left gastric, common hepatic (which gives of gastroduodenal artery and right gastric) and the splenic artery.
The left gastric and gastroduodenal are most involved in PUD
A patient reports Hematemesis. What would you ask further about the emesis? When asking the patient about the color, what information would that give you?
Other than the typical when, how often, HOW MUCH
Coffee-ground or Frank (bright) red.
Coffee-ground emesis indicates limited bleeding whereas frank red indicates ongoing bleeding
A patient reports Malaena. How would they describe it to you?
What are the non-GI bleed causes of Malaena?
Black tarry stools (due to digestion of Hb by bacteria in gut)
Spinach, Iron, and Guinness (beer)
What are the 4 most common causes of upper GI bleeding? Give 2 others
PUD (gastric or duodenal ulcer)
Gastritis/oesophagitis
Mallory Weiss Tear
Oesophageal Varices
Gastric carcinoma, pancreatitis, Dieulafoy Lesion
What is a Mallory Weiss Tear?
Tearing of tissue in the lower oesophagus due to violent coughing or vomiting (including self-induced)
What is a Dieulafoy Lesion
Congenital, large submucosal vessel in the absence of ulcers. May rupture causing bleeding
What is Dyspepsia
Indigestion => uncomfortable upper abdominal pain
What are the clinical features of chronic liver disease? (5) (actual findings on exam)
Jaundice
Ascites
Spider Nevi
Caput Medusae
Hepatomegaly
Gynecomastia
Ecchymosis
What are the features of anemia? (5)
Fatigue
syncope
dyspnea/SOB
Chest pain
Pallor
Dizziness
What are the features of hemorrhagic shock?
Hypotension (incl. orthostatic)
Tachycardia
altered mental state
Tachypnea
QUICK History/Clinical presentation of a patient with an upper GI bleed (up to 10). Good to have a reason for each e.g. rule out or suggestive of a specific diagnosis (included in answer if needed)
Hematemesis/malaena
Hematochezia (fresh bleeding PA)
Abdominal pain (Worse after eating -> PUD/Gastritis vs Duodenal which improves)
Heartburn, reflux, dyspepsia (suggests oesophagitis/ulceration)
Weight loss (PUD avoid eating) + Dysphagia + night sweats (Malignancy)
Features of chronic liver disease (Jaundice, ascites, spider nevi, caput medusae, hepatomegaly, gynecomastia) -> Varices/portal hypertension
Features of Anemia (pallor, fatigue, syncope, SOB/Dyspnea, chest pain) (from blood loss)
!Previous Endoscopy! (iatrogenic)
Medications: Aspirin, warfarin, antiplatelets esp clopidogrel, NSAIDs, Steroids
Features of Hemorrhagic shock: Hypotension (incl. orthostatic), tachycardia, altered mental state, tachypnea (blood loss)
You ask a patient with suspected PUD about the pain they have been having. How would you differentiate between a gastric and duodenal ulcer while sticking to the pain?
Gastric is exacerbated by eating and relieved in duodenal
Gastric will have pain 1-2 hours after eating whereas duodenal is 2-5 hours
Does it awaken you at night. Duodenal more likely to wake the patient up
What is Angiodysplasia
abnormal tortuous dilated vessels in mucosal and submucosal layers of GI tract
What are the Risk factors for PUD?
H. Pylori, NSAIDs, smoking, stress, HTN, increased acid secretion, long-term use of PPI
What are malignant ulcers?
What types of cancers are associated with it? (2)
ulceration due to malignancy e.g. skin (melanoma), breast cancers, Head and neck
What are the RFs for GI bleed (in general)?
PUD RFs (H. Pylori, NSAIDs, smoking, stress, HTN, increased acid secretion, long-term use of PPI)
Chronic Liver disease (Jaundice, ascites, spider nevi, caput medusae, hepatomegaly, gynecomastia)
Atrial Fibrillation (strong association with embolus, bleeding and post-op)
!Angiodysplasia! (abnormal tortuous dilated vessels in mucosal and submucosal layers of GI tract)
Oesophagitis/gastritis
Malignant ulcers (ulceration due to malignancy e.g. skin and breast cancers)