Acute Gastrointestinal Bleeding Flashcards by Lucy Jefford

Define upper GI bleeding.

Bleeding from oesophagus, stomach or duodenum
Proximal to ligament of Trietz

How well did you know this?

Not at all

Perfectly

Define lower GI bleeding.

Bleeding distal to the duodenum.
Distal to ligament of Trietz.

How well did you know this?

Not at all

Perfectly

What is the presentation for upper GI bleeding?

Haematemesis (vomiting fresh blood)
Melaena (black stool)
Elevated urea
Dyspepsia, reflux, epigastric pain

How well did you know this?

Not at all

Perfectly

Which drug can cause upper GI bleeding?

NSAID

How well did you know this?

Not at all

Perfectly

What is the presentation of lower GI bleeding?

Fresh bloods/clots in stool
Magenta stool
Normal urea
Usually painless

How well did you know this?

Not at all

Perfectly

What are peptic ulcers caused by?

Imbalance of natural defences of stomach which can be worsened by the presence of additional factors like peptic enzymes which can digest proteins in the stomach lining.

How well did you know this?

Not at all

Perfectly

How does the stomach usually protect itself from peptic enzymes?

Secretion of mucous which is alkaline which can neutralize the peptic acid.

How well did you know this?

Not at all

Perfectly

List some factors which increases an individual’s risks of peptic ulceration.

H.pylori infection
Smoking
Alcohol
Medication
Ischaemia
Shock

How well did you know this?

Not at all

Perfectly

What can peptic ulceration cause to happen?

Fibrosis and granulation tissue which can increase chances of gastric carcinoma/lymphoma.

How well did you know this?

Not at all

Perfectly

Which type of peptic ulcers are more common- gastric or duodenal?

Duodenal

How well did you know this?

Not at all

Perfectly

What are the risk factors for a duodenal ulcer?

H.pylori infection
NSAIDs/Aspirin

Also alcohol excess or stress ulcers

How well did you know this?

Not at all

Perfectly

How do H.pylori bacteria cause ulceration?

-H.pylori penetrates mucous layer and adheres to epithelium.
-They produce urease which converts urea to ammonia.
-Ammonia acts as a buffer against gastric acid.
-Proliferation of H.pylori
-Ulcer production due to high acid secretion, loss of mucous, epithelial damage and inflammatory cell recruitment.

How well did you know this?

Not at all

Perfectly

Name two common NSAIDs

~(NSAIDs a common cause of peptic ulceration).

Ibuprofen
Diclofenac

How well did you know this?

Not at all

Perfectly

How do NSAIDs cause peptic ulceration?

Inhibit pathways, mainly COX-1, reducing mucous secretion leading to more damage

How well did you know this?

Not at all

Perfectly

As gastric ulcers increase risk of gastric carcinoma, what should be done in those with gastric ulcers?

Repeat endoscopy after 8 weeks.
Ulcer may be sitting over a carcinoma.

How well did you know this?

Not at all

Perfectly

Which syndrome causes poor healing of gastric ulcers?

Zollinger-Ellison syndrome- (gastrin secreting pancreatic tumour)

How well did you know this?

Not at all

Perfectly

What are the causes of gastritis and duodenitis?

Tend to bleed to causes of impaired coagulation:
-Medical conditions
-Anti-coagulants
-Anti-platelets

How well did you know this?

Not at all

Perfectly

RECAP- name some anti-coagulants

Warfarin
Rivaroxaban
Apixaban

How well did you know this?

Not at all

Perfectly

RECAP- name some anti-platelets

Clopidogrel
Ticagrelor

How well did you know this?

Not at all

Perfectly

What may cause bleeding of the oesophagus due to oesophagitis?

-Oesophageal reflux
-Alcohol
-Hiatus hernia
-Systemic illness
-Bisphosphates

How well did you know this?

Not at all

Perfectly

What causes an enlarged spleen?

Portal hypertension

How well did you know this?

Not at all

Perfectly

What causes varices?

Portal hypertension due o liver cirrhosis

How well did you know this?

Not at all

Perfectly

What are varices?

Abnormally dilated collateral vessels

->usually a blockage type thing so blood cannot go through liver so has to find alterative paths causing vessels to swell and expand.

How well did you know this?

Not at all

Perfectly

What is the typical presentation of oesophageal cancer?

Dysphagia/weight loss history

How well did you know this?

Not at all

Perfectly

What can gastric cancer present as?

Gastric ulcer

What is a Mallory-Weiss tear?

Linear tear at oesophageal-gastric junction following a period or retching or vomiting

Diuelafoy is another cause of upper GI bleeding. Describe what it is.

Submucosal arterial vessel erodes through the mucosa, often into the gastric fundus.

Angiodysplasia is another cause of upper GI bleeding. Describe what it is.

Vascular malformations which can occur anywhere in the GI tract. Can cause frequent occult or occult bleeding.

Which conditions are angiodysplasia commonly associated with?

Heart valve replacement

What may be a cause of lower GI bleeding if there is fresh blood passed upon straining but is painless?

Haemorrhoids

What are the more common causes of lower GI bleeding?

Haemorrhoids Diverticular disease

What is diverticulosis? (read carefully!)

Protrusion of the inner mucosal layer through the outer mucosal layer forming a pouch.

When does diverticulosis become diverticulosis?

When diverticulosis becomes inflamed.

What is the treatment for diverticular disease?

Usually self limiting as bleeding often stops spontaneously. However, once bleeding has occurred, there is a higher chance of it happening again.

What are haemorrhoids?

Enlarged vascular cushions around the anal canal

Describe what is experienced w haemorrhoids.

Usually painless but may be painful if thrombosed or external. Bleeding upon defaecation. Associated with constipation, low fibre diet and straining.

What is the treatment for haemorrhoids?

Elective surgical intervention. Topical creams.

What is the treatment for angiodysplasia?

Argon Phototherapy

What is bleeding of angiodysplasia usually caused by?

Anti-coagulants Anti-platelets

What are two forms of colonic neoplasma?

Colonic polyps Colonic neoplasm

What is ischaemic colitis?

Disruption of blood flow to the colon

How does ischaemic colitis present?

Crampy abdominal pain, usually in those >60

What are some potential complications of ischaemic colitis?

Gangrene Perforation

What is radiation proctitis?

Inflammation caused by radiotherapy

Which cancer's is radiation proctitis usually associated with?

Prostate cancer Cervical cancer

How does radiation proctitis usually present?

Crescendo PR bleeding, often occurs 1 or 2 years after radiotherapy

What is the treatment for radiation proctitis?

-APC- using ionised gas to clot blood/form scar tissue to prevent bleeding -Sulcrafate enemas- forms protective layer to prevent bleeding -Hyperbalic oxygen- 100% oxygen

List the causes of lower GI bleeding which originate in the small intestine.

Meckel's diverticulum Small bowel angiodysplasia Small bowel tumour Small bowel ulceration Aortoentero fistula- following AAA repair

Which drug is associated with small bowel ulceration as a cause of lower GI bleeding?

NSAIDs

List some of the investigations used for the small bowel to identify causes of lower GI bleeding

CT angiogram using contrast Meckel's scan Capsule endoscopy (swallowing a pill camera) Double balloon enteroscopy

What is Meckel's diverticulum?

Gastric reminant mucosa

Where would you see the Gastric reminant mucosa found in Meckel's diverticulum?

2ft from ileocaecal valve, 2inches long

Why is Meckel's diverticulum bad?

The gastric reminant mucosa may produce gastric acid which can cause ulcers

What is meant by shock?

Circulatory collapse resulting in inadequate tissue oxygen delivery leading to global hypoperfusion and tissue hypoxia.

How does the body react to shock?

High resp. rate High heart rate Anxiety or confusion Pale, clammy skin Low urine output Low blood pressure

Name some of the scoring systems used to determine whether a patient is at risk of an upper GI bleed.

Rockall score Glasgow Blatchford score

What would be worrying when assessing for shock in terms of a GI bleed?

High urea Low haemoglobin

There is no validated scoring system for assessing risk of a lower GI bleed. However, what are some of the symptoms which could suggest one?

Advanced age Co-morbidity- if a patient has 2 or more conditions Inpatients Initial shock Drugs- like NSAIDs and Aspirin

If the bleeding comes from the upper GI, which investigation is used to make a specific diagnosis?

Endoscopy

If the bleeding comes from the lower GI, which investigation is used to make a specific diagnosis?

Colonoscopy or CT angiogram (especially CT if patient has ongoing bleeding) ->think, if it's lower, putting a camera down the throat isn't going to be effective as it's going to have a long way to travel before getting to the issue.

If a patient has a GI bleed, it is important to stop any medications that might be contributing to this. It may be useful to use things to reverse certain medications. What could be used to reveres the affects of warfarin, a commonly used anticoagulant?

Vitamin K Beriplex

If stopping certain drugs, what is important to remeber?

To start them again when the patient is stable., after about five days, or they could die from other conditions like MI.

Which specific medications may reduce the bleeding?

PPIs Tranexamic acid ~(can increase thrombosis risk so have to be careful)

What is the first stage of management for patients with a GI bleed, before calculating their risk score?

Resuscitate them and get them stable

What can endoscopes allow as well as identifying the condition?

Can be used to direct medicine directly down the tube to the issue.

What are some of the endoscopic therapy options to reduce bleeding?

Injection of adrenaline Thermal contact w/gold probe Mechanical clip

What is the most effective combination of endoscopic therapy to stop bleeding?

Injection of adrenaline + thermal gold probe or clips.

Why are PPI's useful in those with ulcers?

Proton pump pumps out positive H ions which increase acid secretion and cause an ulcer, so inhibiting this pump reduces acid.

What should be done if the ulcer bleeding is ongoing and cannot be treated endoscopically?

Angiography with embolization (finding source of bleeding and then embolising it). Laparotomy

What is the management for varices?

Endoscopy with endotherapy

Where do varices most often occur?

Oesophagus

What works well for the vast majority of oesophageal varices?

Band ligation

If endoscopic treatment for varices isn't sufficient, what may be carried out alongside the procedure?

-Terilpressen (drug) -Antibiotics -Reverse abnormal coagulation

Which blood supply does terlipressen vasoconstrict?

Splanchnic blood supply

What are the treatment options for varices if bleeding is ongoing and uncontrollable endoscopically?

Senstaken-Blakemore tube (tube that goes through nose or mouth to the stomach and has a balloon at the bottom) TIPSS

Discuss what happens in TIPSS

Entry into systemic blood supply via the transjugular vein without going through a very scarred liver

Acute Gastrointestinal Bleeding Flashcards

(77 cards)