Acute gastro-intestinal bleed

Question 1

What are the risk factors for acute upper GI bleeds?

Answer 1

Alcohol abuse
Liver disease
NSAID/anticoagulant use
GORD
Malignancy
Severe/prolonged vomiting

Question 2

What are the causes of acute upper GI bleeds?

Answer 2

Drug abuse - NSAIDs/alcohol
Reflux oesophagitis
Oesophageal varices
Gastric varices
Mallory-Weiss syndrome
Gastric/duodenal ulcer
Gastric carcinoma
Haemmorhagic gastropathy and erosions

Question 3

What are the signs of an acute upper GI bleed?

Answer 3

Haematemasis 
Melaena
Tachycardia
Pallor
Hypotension 
Cold peripheries

Question 4

What are the symptoms of an acute upper GI bleed?

Answer 4

Haematemasis
Melaena
Abdominal pain
Weakness
Dizziness
LOC
Feeling cold

Question 5

What other conditions might present in a similar way to acute upper GI bleeds?

Answer 5

Abdominal Aortic Aneurysm
Acute Gastritis
Barrett Esophagus
Oesophageal Cancer
Oesophageal Varices
Oesophagitis
Gastric Cancer
Gastric Outlet Obstruction
Gastric ulcer
Gastrinoma
Peptic Ulcer Disease

Question 6

How would you investigate an acute upper GI bleed?

Answer 6

FBC, U+Es, LFTs, coagulation screen, group and save

Urgent endoscopy in shocked patients/liver disease

Question 7

What would you tell the patient/how would you explain an acute upper GI bleed to them?

Answer 7

Depends on aetiology…

They had a tear/burst blood vessel in their stomach or gullet which has caused them to vomit some of the blood. Their stools are black/tarry because of the blood that has passed through their digestive system. They have been feeling weak/faint/in shock because of the loss of blood. After stopping the bleeding it’s most important to figure out why it happened with endoscopy/blood tests.

Question 8

How do you think the patient and/or family might be affected by the acute upper GI bleed? Will it affect their ability to work/care for themselves?

Answer 8

Depends on the aetiology.

When caught early and treated promptly the patient should make a full recovery from the bleeding itself, but whether or not it will recur and how likely that is depends on the cause.

The incident itself is likely to be very frightening to the patient and their family.

Question 9

What questions is the patient likely to have in the case of an acute upper GI bleed?

Answer 9

Why did it happen?
Will it happen again?
Is there anything I can do to stop it from happening again?
Are their any treatments that can stop it from happening again?

Question 10

What pharmacological treatments are of use in acute upper GI bleeds?

Answer 10

In ulcers - IV omeprazole for 72 hours, direct injection of adrenaline

In shocked patients: blood tx or colloids

Question 11

What surgical/other treatments may be used for an acute upper GI bleed?

Answer 11

Banding/stenting of varices

Thermal coagulation of ulcers

Question 12

What are the causes of acute lower GI bleeds?

Answer 12

Diverticular disease
Ischaemic colitis
(Small bleeds may be caused by haemmorrhoids, anal fissure etc)
Neoplasia
Angiodysplasia
Polyps
Ulcers

Question 13

What are the signs of an acute lower GI bleed?

Answer 13

Maroon stools, with LGIB from the right side of the colon
Bright red blood per rectum with LGIB from the left side of the colon
Melena with cecal bleeding
(if massive may be bright red from all parts of lower GI tract)
Signs of shock (hypotension, tachycardia etc)
Hb <6
If cause by colitis - fever, dehydration, abdo pain etc

Question 14

What are the risk factors for acute lower GI bleeds?

Answer 14

Age (>65)
Infirmity
Liver disease
Coagulopathy
IBD
Hx cancer/radiotherapy

Question 15

What are the symptoms of an acute lower GI bleed?

Answer 15

Abdo pain
Rectal bleeding
Syncope
Perianal pain

Question 16

What other conditions might present in a similar way to acute lower GI bleeds?

Answer 16

Angiodysplasia of the Colon
Anorectal Abscess
Colitis
Colon Cancer
Colonic Polyps
Crohn Disease
Diverticulitis
Endometriosis
Inflammatory Bowel Disease
Intussusception
Meckel Diverticulum
Small Intestinal Diverticulosis
Ulcerative Colitis
Upper Gastrointestinal Bleeding

Question 17

How would you investigate an acute lower GI bleed?

Answer 17

Bloods: FBC, coagulation profile (prothrombin time etc), ?LFTs, ?INR, U+Es

Fibre optic flexible colonoscopy

Angiography

CT abdo pelvis with contrast

Question 18

What would you tell the patient/how would you explain an acute lower GI bleed to them?

Answer 18

Something (ischaemic colitis, ulcer, tumour etc) has caused them to bleed from their lower intestine and this blood has come out of their bottom. We need to find the source of the bleeding and stop it as soon as possible, This may involve a small, flexible camera being passed up their back passage.

Question 19

How do you think the patient and/or family might be affected by the acute lower GI bleed? Will it affect their ability to work/care for themselves?

Answer 19

They would probably be very frightened and possibly (depending on aetiology) be feeling very unwell. Their activities of daily living would be limited by how unwell they feel and/or how much blood loss they are experiencing.

Question 20

What questions is the patient likely to have in the case of an acute lower GI bleed?

Answer 20

Am I going to die?
Why has this happened?
Is their anything I can do to stop this from happening again?

Question 21

What pharmacological treatments are of use in acute lower GI bleeds?

Answer 21

Vasoconstrictive agents:

• vasopressin
• epinephrine (also local injection)
• propranolol

Question 22

What surgical/other treatments may be used for an acute lower GI bleed?

Answer 22

Colonoscopy to localise the bleeding site then:
- Bipolar probe coagulation
- Clipping
Superselective embolisation
In extreme circumstances:
- segmental bowel resection
- subtotal colectomy