Acute GI Bleed

Question 1

define an upper gastrointestinal haemorrhage

Answer 1

proximal to ligament treitz; stomach, oesophagus, duodenum

Question 2

define lower GI haemorrhage

Answer 2

distal to ligament treitz; jejunum, ileum, colon

Question 3

define haematemesis

Answer 3

vomiting fresh blood

Question 4

define melaena

Answer 4

black tarry faeces with digested blood

Question 5

what can cause gastritis and duodenitis?

Answer 5

> h. pylori
NSAID, aspirin
alcohol
stress / systemic illness

Question 6

name the five most common causes of acute UGI haemorrhage

Answer 6

> peptic ulcer
> oesophagitis
> gastritis
> erosive duodenitis
> varices

Question 7

what can cause oesophagitis?

Answer 7

> reflux
> hiatus hernia
> alcohol
> systemic illness
> bisphosphonates

Question 8

why can cirrhosis lead to varices?

Answer 8

it causes portal hypertension

Question 9

what malignancies can lead to acute UGI haemorrhage?

Answer 9

> oesophageal cancer

> gastric cancer

Question 10

what can cause a Mallory Weiss tear?

Answer 10

retching and vomiting

Question 11

what is the aetiology of LGI haemorrhage?

Answer 11

> diverticular disease
> vascular malformations
> ischaemic colitis
> haemorrhoids
> IBD
> neoplasia
> radiation

Question 12

what is diverticular disease?

Answer 12

protrusion of the inner mucosal lining through the outer muscular layer forming a pouch with symptoms

Question 13

what is the aim of assessment of GI haemorrhage?

Answer 13

> identify the sick patient with life threatening hemodynamic compromise then initiating appropriate resuscitation
identify the low risk patients the discharging them or carrying out an outpatient investigation

Question 14

what may be in the presenting complaint of GI haemorrhage?

Answer 14

> vomiting blood
> black stools
> dyspepsia
> dizzy, collapse
> weight loss

Question 15

what may be in the past medical history of GI haemorrhage?

Answer 15

> chronic liver disease
chronic cardiac, renal disease
malignancy
previous GI haemorrhage

Question 16

what may be seen in the drug history in a GI haemorrhage?

Answer 16

> antiplatelets
NSAID
over the counter medication

Question 17

when might an UGI haemorrhage present with fresh blood being passed in stool?

Answer 17

if there is rapid transit

Question 18

what initial investigations should you carry out in GI haemorrhage?

Answer 18

> blood tests
blood gas
12 lead ECG

Question 19

what blood tests do you carry out in the initial investigations of GI haemorrhage?

Answer 19

> FBC
U and E’s
coagulation
cross match

Question 20

what scoring system is used in Aberdeen?

Answer 20

the Glasgow-Blatchford score

Question 21

how is a Glasgow-Blatchford score of 0/1 managed?

Answer 21

consider outpatient investigation or discharge

Question 22

how is a Glasgow-Blatchford score of 2 managed?

Answer 22

inpatient investigation

Question 23

What percentage of patients with a score >6 are at greater risk of needing intervention?

Answer 23

50%

Question 24

what patients are taken to the bleeding unit/HDU?

Answer 24

the haemodynamically compromised

Question 25

what are the targets for resuscitation?

Answer 25

> alert > urine output > Hb 80

Question 26

what fluid is used in resuscitation?

Answer 26

> crystalloid | > blood products

Question 27

define shock

Answer 27

circulatory insufficiency resulting in inadequate oxygen delivery, global hypoperfusion and tissue hypoxia

Question 28

what are the signs/symptoms of shock?

Answer 28

``` > tachypnoea > tachycardia > hypotension > oliguria > anxiety/confusion > cold, clammy skin ```

Question 29

describe non-endoscopic management

Answer 29

> nil by mouth > stop harmful medication (antiplatelets, anticoagulation, NSAID, antihypertensive) > reversal of harmful medication > correct coagulopathy

Question 30

what is the effect of early endoscopy on high risk groups?

Answer 30

> reduced transfusion > reduced length of stay > reduced re-bleed > reduced surgical therapy

Question 31

what endoscopic therapies are there for peptic ulcers?

Answer 31

``` > Injection (adrenaline) > Thermal (gold probe) > Mechanical (clip) > Haemospray Combination therapy is most effective (adrenaline + thermal/clips) ```

Question 32

why should you carry out a PPI infusion post endoscopic procedure?

Answer 32

> stabilises clot > increases gastric pH > reduces re-bleed

Question 33

in what circumstances should there be a high degree of suspicion of variceal haemorrhage?

Answer 33

> signs of chronic liver disease > history of known liver disease > known varices

Question 34

what sort of complications cause patient death in variceal haemorrhage?

Answer 34

> sepsis > renal failure > encephalopathy

Question 35

what is the management in variceal haemorrhage?

Answer 35

``` > GCS reduction > resuscitation (avoid saline in cirrhosis) > blood products > senior support > gastroenterology ```

Question 36

what non endoscopic management is there for variceal haemorrhage?

Answer 36

> terlipressin > antibiotics > sengstaken-blakemore tube

Question 37

what endoscopic management is there for variceal haemorrhage?

Answer 37

> band ligation > glue injection > transjugular intrahepatic portosystemic shunt

Question 38

what are the risk factors for the outcome of LGI haemorrhage?

Answer 38

``` > age > co-morbidity > inpatients (higher mortality rate) > initial shock > medication (aspirin and NSAIDs increase risk of LGI bleeding) ```

Question 39

what surgical management is there for LGI haemorrhage?

Answer 39

> subtotal colectomy | > segmental resection

Question 40

what imaging investigations should be carried out in LGI haemorrhage?

Answer 40

> flexible sigmoidoscopy or full colonoscopy If no colonic cause found and UGI bleed excluded, consider small bowel origin so > CT angiogram > Meckel's scan (scintigraphy) > Capsule endoscopy > Double balloon enteroscopy

Question 41

What is the Glasgow-Blatchford score based on?

Answer 41

``` > Blood urea > Haemoglobin > Systolic blood pressure > Pulse >100 > Presentation with melaena > Presentation with syncope > Hepatic disease > Cardiac failure ```