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07. Year 2: Alimentary System > Acute Gastrointestinal Bleeding > Flashcards

Acute Gastrointestinal Bleeding Flashcards

1
Q

What is the incidence of GI bleed in the UK?

A

180/100000

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2
Q

What is the overall mortality of acute GI bleed?

A

10%

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3
Q

What mainly affects the outcomes of GI bleed?

A

Identification and promp management

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4
Q

Where can upper GI bleeding occur from?

A

Oesophagus

Stomach

Duodenum

anywhere proximal to ligament of Trietz

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5
Q

Where can lower GI bleeding occur from?

A

Bleeding distal to duodenum (jejunum, ileum, colon)

Distal to ligament of Trietz

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6
Q

What is the clinical presentation of upper GI bleed?

A

Haematemesis

Melaena

Elevated urea (digested blood turns haem into urea)

Dyspepsia, reflux, epigastric pain

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7
Q

What is the clinical presentation of lower GI bleeding?

A

Fresh blood/clots

Magenta stools

Normal urea (rarely elevated if proximal small bowel origin)

Typically painless

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8
Q

What can cause upper GI bleeds in the oesophagus?

A

Oesophageal ulcer

Oesophagitis

Oesophageal varices

Mallory Weiss Tear

Oesophageal malignancy

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9
Q

What can cause upper GI bleeds in the stomach?

A

Gastric ulcer

Gastritis

Gastric varices

Portal hypertensive gastropathy

Gastric malignancy

Dieulafoy

Angiodysplasia

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10
Q

Are duodenal ulcers or gastric ulcers more common?

A

Duodenal ulcers (75%)

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11
Q

What are risk factors for peptic ulcers?

A

Helicobacter pylori

NSAIDs/aspirin

Alcohol excess

Systemic illness (stress ulcers)

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12
Q

How does helicobacter pylori lead to gastric ulcers?

A

Produces urease -> amonia produced -> buffers gastric acid locally -> increased acid production

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13
Q

How does NSAIDs lead to gastric ulcers?

A

Prostaglandin production -> reduces mucus and bicarbonate excretion -> reduces physical defences

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14
Q

Why when a gastric ulcer is present is a repeat endoscopy indicated at 8 weeks?

A

They may have been sitting over a gastric carcinoma

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15
Q

What is Zollinger-Ellison syndrome also known as?

A

Gastrin-secreting pancreatic tumour

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16
Q

How does Zollinger-Ellison syndrome impact duodenal ulcers?

A

Causes poor healing of duodenal ulcers

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17
Q

What are the risk factors for gastritis and duodenitis similar to?

A

Risk factors for gastric and duodenal ulcer

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18
Q

What tends to cause gastritis and duodenitis to bleed?

A

Medical conditions

Anti-coagulants

Anti-platelets

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19
Q

What are examples of anti-coagulants?

A

Warfarin

Rivaroxaban

Apixaban

Dabigatran

LMWH

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20
Q

What are examples of anti-platelets?

A

Clipidogrel

Ticagrelor

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21
Q

What are risk factors for oesophagitis?

A

Reflux oesophagitis

Hiatus hernia

Alcohol

Biphosphonates

Systemic illness

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22
Q

When is oesophagitis most likely to have significant bleeding?

A

When on anti-platelets or anti-coagulatns

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23
Q

What are varices secondary to?

A

Portal hypertension, usually due to liver cirrhosis

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24
Q

What are varices?

A

Abnormally dilated collateral vessels

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25
Q

What are different types of varices?

A

Oesophageal (90%)

Gastric (8%)

Rectal and splenic (rare)

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26
Q

What are examples of upper GI malignancies?

A

Oesophageal cancer

Gastric cancer

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27
Q

What is a Mallory-Weiss tear?

A

Linear tear at oesophageal-gastric junction

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28
Q

What does a Mallory-Weiss tear follow a period of?

A

Vomiting and retching

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29
Q

What is Diuelafoy?

A

Submucosal arteriolar vessel eroding through mucosa

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30
Q

Where does Diuelafoy commonly occur?

A

Gastric fundus

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31
Q

What is an angiodysplasia?

A

Vascular malformation

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32
Q

Where can an angiodysplasia occur?

A

Anywhere along the GI tract

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33
Q

What chronic conditions is angiodysplasia associated with?

A

Heart valve replacement

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34
Q

What investigation is done for upper GI bleeding?

A

Upper endoscopy

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35
Q

When should an endoscopy be done for an upper GI bleed?

A

Within 24 hours, sooner if unstable

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36
Q

What are some colonic causes of lower GI bleeding?

A

Diverticular disease

Haemorrhoids

Vascular malformation (angiodysplasia)

Neoplasia (carcinoma or polyps)

Ischaemic colitis

Radiation enteropathy/proctitis

IBD (such as ulcerative colitis or Crohn’s disease)

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37
Q

What does diagnosis of a lower GI bleed require?

A

Flexible sigmoidoscopy or full colonoscopy

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38
Q

What is diverticular disease?

A

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

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39
Q

What does diverticulosis mean?

A

Presence

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40
Q

What does diverticulitis mean?

A

Inflammation

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41
Q

What is the main risk of diverticular disease?

A

Further bleeding (10% chance of reccurent at one year, 25% at four years)

42
Q

What are haemorrhoids?

A

Enlarged vascular cushions around anal canal

43
Q

When are haemorrhoids painful?

A

If thrombosed or external

44
Q

What are haemorrhoids associated with?

A

Straining/constipation/low fibre diet

45
Q

What is the treatment for haemorrhoids?

A

Elective surgical intervention

46
Q

What is bleeding due to angiodysplasia often precipitated by?

A

Anticoagulants/antiplatelets

47
Q

What is the treatment for angiodysplasia?

A

Argon phototherapy

Medication including tranexamic acid, thalidomide

48
Q

What are different kinds of colonic neoplasia?

A

Colonic polyps or carcinoma

49
Q

What is ischaemic colitis?

A

Disruption in blood supply to the colon

50
Q

What determines what area of the colon ischaemic colitis affects?

A

Which blood vessels are affected

51
Q

What does ischaemic colitis typically affect?

A

Descending/sigmoid colon

52
Q

What are possible complications of ischaemic colitis?

A

Gangrene

Perforation

53
Q

What is usually present in radiation proctitis?

A

Previous history of radiotherapy (cerival cancer, prostate cancer)

54
Q

What is the treatment for radiation proctitis?

A

APC

Sulcrafate enemas

Hyperbaric oxygen

55
Q

What does treatment of IBD depend on?

A

Extent/severity

56
Q

What investigations are done for acute lower GI bleeding?

A

Flexible sigmoidoscopy

Colonoscopy

CT angiogram

57
Q

When should small bowel origin of bleeding be considered?

A

If no colonic cause is found and upper GI bleeding is excluded

58
Q

What percentage of GI bleeds are small bowel?

A

5%

59
Q

What are small bowel causes of lower GI bleeding?

A

Meckel’s diverticulum

Small bowel angiodysplasia

Small bowel tumour

Small bowel ulceration (NSAID associated)

Aortoentero fistulation

60
Q

What investigations can be done to look at bleeding in the small bowel?

A

CT angiogram

Meckel’s scan (Scintigraphy)

Capsule endoscopy

Double balloon enteroscopy

61
Q

What is Meckel’s diverticulum?

A

Gastric reminant mucosa 2 feet from ileocaecal valve that is 2 inches long

62
Q

What is used to diagnose Meckel’s diverticulum?

A

Nuclear scintgraphy

63
Q

What is gastrointestinal bleeding managed by?

A

ABCDE

airway

breathing

circulation

disability

exposure

64
Q

What management in terms of circulation is done for gastrointestinal bleeding?

A

Wide broad IV access to give IV fluids, blood transfusions

Urgen blood samples to lab (FBC, U&Es, LFT, coagulation, blood group)

Blood transfusions if Hb<7g/dL or ongoing active bleeding

65
Q

When is a blood transfusion given for gastrointestinal bleeding?

A

If Hb<7g/dL

66
Q

What does the management of GI bleeding involve?

A

ABCDE

Endoscopy once stable

Withhold/reverse contributory medication if able to

Blood products if ongoing bleeding

Specific medications

Consider CT angiography/interventional radiology/surgical intervention as appropriate

67
Q

When is an IV for GI bleeding given?

A

If platelets < 50

68
Q

When is fresh frozen plasma (FFP) given for GI bleeding?

A

If INR or APTT > 1.5x normal range or Cryoprecipitate if fibrinogen <1.5g/L

69
Q

What is shock?

A

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

70
Q

What is the clinical presentation of shock?

A

Tachypnoea

Tachycardia

Anxietry or confusion

Cool clammy skin

Loguria

Hypotension

71
Q

What are the different stages of shock?

A

Stage 1

Stage 2

Stage 3

Stage 4

72
Q

What things does shock classification consider?

A

Volume lost

% blood lost

Respiratory rate

Heart rate

Blood pressure

Pulse pressure

Consciousness level

73
Q

What is considered to be stage 1 shock?

A
74
Q

What is considered to be stage 2 shock?

A
75
Q

What is considered to be stage 3 shock?

A
76
Q

What is considered to be stage 4 shock?

A
77
Q

What is used for risk stratification for upper GI bleeding?

A

Rockall score

78
Q

Other than Rockall score, what else can be used to risk stratification of upper GI bleeding?

A

Blatchford score

79
Q

What are the different stages of the rockall score?

A

0

1

2

3

80
Q

What does the rockall score consider?

A

Age

Shock

Co-morbidity

Diagnosis

Major stigmata of recent haemorrhage

81
Q

What is considered 0 for the rockall score?

A
82
Q

What is considered 1 for rockall score?

A
83
Q

What is considered 2 for the rockall?

A
84
Q

What is considered 3 for the rochall score?

A
85
Q

What things are considered for the blatchford score?

A

Blood urea (mmol/L)

Haemoglobin (g/L)

Systolic blood pressure

Pulse

Hepatic disease

Cardiac failure

86
Q

What is low risk criteria for Glasgow blatchford score?

A

Urea < 6.5mmol/L

Haemoglobin >= 130g/L (men) or >= 120g/L (women)

Systolic blood pressure >= 110mmHg

Pulse < 100bpm

Absence of melaena, syncope, cardiac failure or liver disease

87
Q

What score for the blatchford score is associated with greater than 50% risk of needing an intervention?

A

>=6

88
Q

What scoring system is used for risk stratification of lower GI bleeding?

A

There is no validated scoring system

89
Q

Is the relationship between age and mortality more defined in lower or upper GI bleeding?

A

Acute lower GI bleeding occurs most often in the elderly

Age and mortality association more associated with lower GI bleeding

90
Q

What is the relationship between co-morbidity and severe bleed?

A

Presence of two co-morbidities doubles the change of a severe bleed

91
Q

How does inpatients who have rectal bleeding impact mortality?

A

Inpatients with rectal bleeding have 23% mortality compared with 3.6%

92
Q

How do drugs impact the risk of lower GI bleeding?

A

Patients taking aspirin and NSAIDS are at increased risk

OR 1.8-2.7

93
Q

What is the benefit of using dedicated teams to manage acute GI bleeding?

A

Improved mortality

94
Q

Why does having dedicated teams improve the outcome of acute GI bleeding?

A

Protocolised care

Prompt resuscitation

Close medical and surgical liaison

95
Q

What is the management of a peptic ulcer?

A

Proton pump inhibitor

Endoscopy with endotherapy

If bleeding is uncontrollable, then laparotomy

96
Q

What are endoscopic therapy to pathology options for the management of a peptic ulcer?

A

Injection (adrenaline)

Thermal

Mechanical (clip)

Haemospray

Combination therapy is the most effective

97
Q

What is the management for a peptic ulcer when bleeding is uncontrollable?

A

Angiography with embolisation

Laparotomy

98
Q

What is the management of varices?

A

Endotherapy

Intubated for airway protection

IV Terlipressin

IV broad spectrum antibiotics

Correct coagulopathy

99
Q

What are different kinds of endotherapy for oesophageal varices?

A

Band ligation

Glue injection

100
Q

What are different kinds of endotherapy for gastric varices?

A

Glue injection

101
Q

What are different kinds of endotherapy for rectal varices?

A

Glue injection

102
Q

What is Terlipressin?

A

Vasoconstrictor of splanchnic blood supply, reducing portal pressures by reducing blood flow

07. Year 2: Alimentary System (41 decks)

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