A3- Lower + Upper GI Bleeding

Question 1

WHat is GI Bleeding

Answer 1

• Blood loss originating from any point of GI tract (mouth to anus).

Question 2

What is lower GI bleed

Answer 2

• Blood loss originating from site distal to ligament of Treitz

Question 3

What is upper GI bleed

Answer 3

• Blood loss originating from site proximal to ligament of Treitz.

Question 4

What is Melaena?

Answer 4

• Black tarry faeces that are associated with UGI bleeding.

Question 5

What is haematemesis

Answer 5

• Vomiting of blood

Question 6

What is Haematochezia?

Answer 6

• Passage of maroon or bright red blood or blood clots per anus.

Question 7

Ligament of Treitz

Answer 7

Defines the bend between the duodenum from the jejunum

Question 8

WHat does occult lower GI bleeding mean

Answer 8

it is a classificaiton

patients usually present with anaemia

Question 9

What do you ask about the blood

Answer 9

Colour: •Bright red • Dark red, maroon • Clots

Consistency: • Tarry, sticky • Jelly like • Fluid

Smell: • Fresh blood •Altered digested blood

Question 10

What to ask in history of compliant? bleeding

Answer 10

When

How long/how often/how often

abdominal pain

associated symptoms

weight loss, red flag symptoms

Question 11

PMHx

what to look out for in bleedign

Answer 11

IHD, angina

Diverticular disease

Haematological disorders

Surgical Hx

Recent travel

Question 12

What medicaiton do we need to know about in relation to GI bleedign

Answer 12

Anticoagulants

iron tablets

NSAIDs

Question 13

What to look out for in social hx?

Answer 13

alcohol

smoking

fitness assessment

Question 14

WHat to look out for in skin, neurology and abdomen for patient with GI bleeding

Answer 14

Question 15

Differential diagnosis

for GI bleedign

Answer 15

Question 16

Management of ccult to moderate LGI bleed

Answer 16

Ensure patient is haemodynamically stable

History and examination (DRE and proctoscopy)

Biochemistry: Full blood count, iron studies, faecal calprotectin

Imaging: Flexible sigmoidoscopy, colonoscopy, CT colonography, CT abdomen, MRI abdomen

Referral to tertiary care – ? Capsule (VCE)

Question 17

Management of massive LGI bleed

Answer 17

Main principles are

1. resuscitate 2. stop the bleeding

Question 18

WHat do score do you use to check if the patient is safe to be discharged after a lower GI bleed

Answer 18

Oakland Score

Question 19

What components do you look at in th eoakland score?

Answer 19

Question 20

What is the resuscitation principles for GI bleed

Answer 20

• Enlist help and escalate early.
• X2 large bore cannulae.
• Bloods for crossmatch.
• Fluid resuscitation with crystalloid first then think blood.
• Remember massive transfusion protocol.
• Monitor urine output.
• Reverse anticoagulation if possible
• TXA

Question 21

what is the Massive transfusion Protocol?

Answer 21

Question 22

Significance of colonoscopy?

Answer 22

• Can be diagnostic of all sources of bleeding.
• Efficient and cost effective.
• Can have therapeutic possibilities.

Cons:

• Less useful in major bleed.
• Good views require bowel prep.
• Invasive.
• Difficult to complete out of hours.

Question 23

What is the Sensitivity and Specificity of CT angiography

Answer 23

Sensitivity 86%

Specificity 95%

Question 24

Pros and Cons of Mesenteric angiography

Answer 24

• No bowel prep required. • Therapeutic possibilities with high accuracy and localisation.
• Requires active bleeding. • Less sensitive to venous bleeds (need prolonged exposure times). •Invasive therefore potential complications.

Question 25

Pros and COns of Radionuclide Scintigraphy

Answer 25

* Label red blood cells detect the slowest bleeding rate 0.1- 0.5mL/min but cannot reliably localise site of bleeding. • Non invasive. • No bowel prep. • Repeatable investigation. * Non therapeutic. • May delay intervention. • Diagnosis has to be confirmed by other means

Question 26

Significance of capsule endoscopy?

Answer 26

* Can identify small bowel bleeding sites * Role in active bleeding to be defined.

Question 27

If surgery is done known source is called unknown source is called

Answer 27

* If known source –selective colectomy. * If unknown source – on table endoscopy +/- subtotal colectomy

Question 28

Common Upper GI bleeds?

Answer 28

Question 29

In the “other/no obvious cause" category for upper GI bleed examples?

Answer 29

* Angiodysplasia * Gastric antral vascular ectasia (GAVE) * Dieulafoy lesion * Hereditary haemorrhagic telangiectasia (HHT) * Portal hypertensive gastropathy * Aorto-duodenal or Aorto-enteric fistula

Question 30

What is the (Glasgow) Blatchford Score

Answer 30

Assessment tool to be done to aid decision for when endoscopy should be performed ➢ Score of 0-2

Question 31

What is the score called where you are Establishing severity, likelihood, and mortality

Answer 31

Rockall Score

Question 32

How do you classify how much blood is lost?

Answer 32

Question 33

Initial Management for upper GI bleed

Answer 33

•Airway •Breathing •Circulation •Disability •Exposure (Don’t Ever Forget Glucose) (Round you go again)

Question 34

Blood-related investigations for suspected UGI bleed

Answer 34

* FBC * U/E * LFTs * INR/Coag * Blood Gas + Glucose * Group and Save Vs Crossmatch Vs Major haemorrhage protocol

Question 35

Management of non-variceal bleed

Answer 35

As always these are your options ➢ (Non-pharmacological/pharmacological/conservative) ➢ Endoscopic ➢ Interventional Radiology: angiography and embolisation ➢ Surgical: resection

Question 36

Endoscopic management of non-variceal bleed

Answer 36

Three main methods for achieving haemostasis ➢ Adrenaline + Mechanical: Clips ➢ Adrenaline + Thermal coagulation: heat probes, argon plasma ➢ Adrenaline + Fibrin or thrombin: Haemospray

Question 37

Post-endoscopy intervention: Pharmacological treatment

Answer 37

1) Existing medication • Education on NSAID use • Decide risk vs benefit for anticoagulation, when to restart/ should we restart 2) Eradication • H. pylori eradication 3) Hong Kong Regime for PPI • 80mg Omeprazole stat + 8mg/hour over 72 hours 4) Rescope

Question 38

What is the Child-Pugh Score

Answer 38

he Child-Pugh score is a system for assessing the prognosis — including the required strength of treatment and necessity of liver transplant — of chronic liver disease, primarily cirrhosis. It provides a forecast of the increasing severity of your liver disease and your expected survival rate.

Question 39

Management of acute Variceal Bleed At presentation

Answer 39

➢ Fluid resus (blood vs saline vs gelofusin vs HAS) ➢ Terlipressin (2mg IV 4 hourly) ➢ Prophylactic antibiotic therapy (Broadspectrum) At endoscopy ➢ Band ligation ➢ N-butyl-2-cyanoacrylate

Question 40

Management post endoscopy (variceal)

Answer 40

* Fluid replacement – preferably 4.5% HAS * Terlipressin: stop after definitive treatment has been achieved * Pabrinex (I + II) 2 pairs TDS * (Do not confuse with “Parvolex”) * Laxatives (prevents encephalopathy) * Re-scope to assess bands * Varices surveillance