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3: MED2 Y3 - Gastrointestinal [7] > [32] Upper GI Bleeding > Flashcards

[32] Upper GI Bleeding Flashcards

(53 cards)

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1
Q

What is it important to know in the history in a patient with a upper GI bleed?

A 
Previous bleeds
Dyspepsia or known ulcers
Liver disease, or oesophageal varices
Dysphagia or weight loss
Drugs and alcohol
Co-morbidities
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2
Q

What may be found on examination in upper GI bleeding?

A

Signs of CLD

Signs of shock

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3
Q

What signs of shock might be seen on examination in upper GI bleeding?

A 
Cool and clammy
CRT >2s
Decreased BP or postural hypotension
Decreased urine output
Tachycardia
Decreased GCS
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4
Q

What might be found on PR in upper GI bleeding?

A

Melaena

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5
Q

What are the common causes of upper GI bleeding, in order

A 
PUD
Acute erosions/gastritis 
Mallory-Weiss tear
Varices
Oesophagitis
Cancer of stomach or oesophagus
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6
Q

What kind of PUD more commonly causes upper GI bleeding?

A

DU

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7
Q

What is the purpose of a Rockall score?

A

Prediction of re-bleeding and mortality

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8
Q

What % of re-bleeders die in upper GI bleeds?

A

40%

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9
Q

What are the components to the Rockall score?

A

Initial

Final

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10
Q

When is the initial Rockall score calculated?

A

Before endoscopy

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11
Q

When is the final Rockall score calculated?

A

After endoscopy

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12
Q

What is taken into account in the initial Rockall score?

A

Age
Shock - BP and pulse
Co-morbidities

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13
Q

What is taken into account in the final Rockall score?

A

Final diagnosis, and evidence of recent haemorrhage

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14
Q

What evidence for recent haemorrhage might be seen on endoscopy?

A

Active bleeding
Visible vessel
Adherent clot

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15
Q

How can the Rockall score be used to guide surgery?

A

Initial score of 3 or more, or final score of 6 or more are indications for surgery

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16
Q

What is the pathophysiology of oesophageal varices?

A

Portal hypertension leads to dilated veins at the sites of porto-systemic anastomosis

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17
Q

What veins are affected in oesophageal varices?

A

Left gastric

Inferior oesophageal

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18
Q

What % of those with portal hypertension with bleed from varices?

A

30-50%

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19
Q

What is the overall mortality of oesophageal varices?

A

25%

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20
Q

What is the mortality from oesophageal varices dependant on?

A

The severity of liver disease

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21
Q

What are the categories of causes of portal hypertension?

A

Pre-hepatic
Hepatic
Post-hepatic

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22
Q

What are the pre-hepatic causes of portal hypertension?

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A

Portal vein thrombosis

23
Q

What are the hepatic causes of portal hypertension?

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A

Cirrhosis
Schistosomiasis
Sarcoidosis

24
Q

What % of cases of portal hypertension are due to cirrhosis in the UK?

25
What are the post-hepatic causes of portal hypertension?
Budd-Chiari RHF Constrictive pericarditis
26
What is first line in preventing bleeding from oesophageal varices?
Beta-blockers | Endoscopic banding
27
What is second line in preventing bleeding from oesophageal varices?
Beta-blockers Endoscopic banding TIPSS (transjugular intrahepatic porto-sytemic shunt)
28
What happens in TIPSS?
Interventional radiology create an artificial channel between the hepatic vein and portal vein, causing a decrease in portal pressure
29
How is an artificial channel between the hepatic vein and portal vein created in TIPSS?
Colapinto needle creates a tract through the liver parenchyma, which is expanded using a balloon and maintained by placement of a stent
30
What is the role of TIPSS in oesophageal varices?
It can be used prophylactically, or acutely if endoscopic therapy fails to control variceal bleeding
31
What are the steps in the management of upper GI bleeding?
1. Resuscitate 2. Blood if remains shocked 3. Maintenance 4. Urgent endoscopy 5. Medications and monitoring
32
What is involved in resuscitation in upper GI bleeding?
Keep head down 100% oxygen, protect airway 2x14G cannula, and IV crystalloid infusion up to 1L Take bloods
33
What bloods need to be taken during the resuscitate stage of upper GI bleeding?
``` FBC U&E LFTs Clotting Cross match 6 units ABG Glucose ```
34
What additional step should be taken after resuscitate and giving blood in variceal bleeding?
Terlipressin IV | Prophylactic antibiotics
35
What is terlipressin?
A splanchnic vasopressor
36
What prophylactic antibiotic might be given in variceal bleeds?
Ciprofloxacin 1g/24hours
37
What is involved in maintenance management in upper GI bleeding?
``` Crystalloid IVI, with blood transfusion if necessary Catheter Consider CVP Correct coagulopathy Thiamine if alcoholic Notify surgeons of severe bleeds ```
38
What Hb should be aimed for in the maintenance stage of upper GI bleeding management?
100 or above
39
What CVP should be aimed for in the maintenance stage of upper GI bleeding management?
>5cm H2O
40
How can coagulopathy be corrected in upper GI bleeding management?
Vitamin K FFP Platelets
41
What are the options for achieving haemostasis of a vessel or ulcer in upper GI bleeding?
Adrenaline injection Thermal/laser coagulation Fibrin glue Endoclips
42
What are the options for stopping variceal bleeding
2 of banding, sclerotherapy, adrenaline, and coagulation Balloon tamponade TIPSS
43
What equipment is used for balloon tamponade in variceal bleeding?
Sengstaken-Blakemore tube
44
When is balloon tamponade used in variceal bleeding?
Only when exsanguinating haemorrhage or failure of endoscopic therapy
45
When is TIPSS used in variceal bleeding?
Only if bleeding can't be stopped endoscopically
46
What management is required for upper GI bleeding after endoscopy?
``` Omeprazole IV and continuation of PO Keep NBM for 24 hours Daily bloods H. Pylori testing and eradication Stop NSAIDs, steroids etc ```
47
Why should omeprazole IV be given in upper GI bleeding?
Reduces the risk of rebleeding
48
What should happen after patients with upper GI bleeding have been kept NBM for 24 hours?
Transition to clear fluids, then light diet at 48 hours
49
What daily bloods need to be done after upper GI bleeding?
FBC U&E LFT Clotting
50
What are the indications for surgery in upper GI bleeding?
Re-bleeding Bleeding despite transfusing 6u Uncontrollable bleeding at endoscopy Initial Rockall score >3, or final >6
51
How is surgery for upper GI bleeding performed?
Open stomach, find bleeder, and underrun vessel
52
Why should normal saline be avoided in uncompensated liver disease?
It worsens ascites
53
What should be used instead of saline in uncompensated liver disease?
Blood or albumin for resus, and 5% dex for maintenance

3: MED2 Y3 - Gastrointestinal [7] (44 decks)

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