Acute Gastrointestinal Bleeding

Question 1

What anatomy does upper GI bleeding involve?

Answer 1

Oesophagus
Stomach
Duodenum
Proximal to ligament of treitz

Question 2

What anatomy does lower GI bleeding involve?

Answer 2

Small bowel
Colon
Distal to ligament of treitz

Question 3

What is lower GI bleeding usually but not always?

Answer 3

Fresh or altered blood

Question 4

What is haematemesis?

Answer 4

Vomiting of blood

Question 5

What is malaena?

Answer 5

Passage of black, tarry, loose stools per rectum Acute upper GI bleeding

Question 6

What is haematochezia?

Answer 6

Passage of fresh or altered blood per rectum

Question 7

What are the three most common causes of GI bleeding?

Answer 7

Peptic ulcers (GU/DU)
Gastritis/Erosions
Oesophagitis

Question 8

What should always be checked first when their is GI bleeding?

Answer 8

H.pylori

Question 9

What are varices?

Answer 9

Secondary to portal hypertension, usually due to liver cirrhosis, with abnormally dilated collateral vessels and they are commonly oesophageal (90%)

Question 10

What should be considered if something is spewed up/passed but has been going on for a short while (Not a shock)?

Answer 10

Oesophageal Cancer

OR

Gastric Cancer

Question 11

What is Mallory Weiss Tear?

Answer 11

Linear tear in the lower oesophagus with recurrent retching and vomiting

Question 12

What are the six risk factors for upper GI bleed?

Answer 12

Age (>50years)
Co-morbities
Inpatients
Initial presentation with Haematemesis, Melaena, Shock & Collapse
Continued bleeding after admission
Elevated blood urea

Question 13

What six examinations should be done for acute GI bleeding?

Answer 13

Pulse
BP
Respiratory rate
Saturations
Abdomen
Systems

Question 14

What five investigations should be done for acute GI bleeding?

Answer 14

FBC
U+E's
LFTs
Coagulation
Blood group and x match

Question 15

What are you looking for on examination?

Answer 15

Liver disease (Varices)
Cardiac disease (Angiodysplasia)
Lymphadenopathy/Hepatomegaly (Malignancy)

Question 16

What six things can be donein managing acute GI bleeding?

Answer 16

Resuscitation/Identification of shock
Consider blood transfusion Risk stratification
High risk in HDU
Early endoscopy
Embolisation or surgery if endoscopy won’t work

Question 17

What score can be used to identify whether a patient needs an endoscopy?

Answer 17

Glasgow Blatchford Score

Question 18

How should H.pylori be treated?

Answer 18

One week course of eradication therapy

AND

A further three weeks ulcer healing treatment should be given

Question 19

If on Proton Pump Inhibitors what should be withheld?

Answer 19

Oral anticoagulants
Aspirin
NSAIDs acutely

Question 20

What is the forrest classification of ulcers?

Answer 20

1. Actively bleeding ulcer (80%)
   (a) Spurting
   (b) Oozing
2. Non-actively bleeding ulcer
   (a) Non-bleeding visible vessel
   (b) Adherent clot
   (c) Ulcer with red or blue dark spots
3. Ulcer with clean base

Question 21

How should varices be managed?

Answer 21

Oesophageal - Band ligation or Glue injection
Gastric - Glue injection
Rectal - Glue injection

Question 22

Where does 95% of lower GI bleeding originate from?

Answer 22

Colon

Question 23

What are the major causes of lower GI bleeding?

Answer 23

Diverticular disease
Vascular malformations
Haemorrhoids
Neoplasia
Ischaemic colitis
Radiation enteropathy/proctitis
IBD

Question 24

What is diverticular disease?

Answer 24

Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch

Question 25

What is colonic angiodysplasia?

Answer 25

Vascular malformation where bleeding is precipitated by anticoagulants/antiplatelets

Question 26

What is ischaemic colitis?

Answer 26

Disruption in blood supply to colon which presents with crampy abdominal pain and is self-limiting *Restricted to a specific area and is dusk blue with a swollen mucosa*

Question 27

What are the two causes of Inflammatory Bowel Disease (IBD)?

Answer 27

Ulcerative Colitis OR Crohn's Disease

Question 28

What investigation should be done for lower GI bleeding?

Answer 28

``` CT Angiography Formal angiography Small bowel capsule enteroscopy Double balloon enteroscopy Bloods – FBC, U+E’S, LFTs, Coag & Blood group ```

Question 29

What management options are there for lower GI bleeding?

Answer 29

Colonoscopic haemostatic techniques Angiography and Embolisation Band ligation for haemorrhoids Surgery

Question 30

What are the risk factors for lower GI bleeding?

Answer 30

``` Age Co-morbidity Inpatients Initial shock Drugs ```

Question 31

What are signs of shock? (6)

Answer 31

``` Tachypnoea Tachycardia Anxiety/Confusion Cool clammy skin Low urine output (Oliguria) Hypotension ```