Acute GI Bleeding Flashcards by Jam E

Where does bleeding in the upper GI tract occur?

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

Lower GI bleed is:

Bleeding distal to duodenum (jejunum, ileum, colon)
Distal to ligament of Trietz

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What are signs and symptoms of upper GI bleed?

Haematemesis
Melaena
Elevated Urea
Partially digested blood -> haem -> urea
Associated with dyspepsia, reflux, epigastric pain

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What drugs are upper GI bleeds associated with?

•Non-steroidal anti-inflammatory use

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What are signs and symptoms of lower GI bleed?

Fresh blood/clots
Magenta stools
Normal urea (rarely elevated in proximal small bowel)
Typically painless
More common in advanced age

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What are the causes of upper GI bleeding?

ULCERS

Oesophagus:

Oesophageal varices
Mallory Weiss Tear (tear in the mucous membrane, or inner lining, where the esophagus meets the stomach)
Oesophageal malignancy

Stomach:

Gastric varices
Gastric malignancy (may be under an ulcer)
Dieulafoy - a large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes through mucosa and bleeds
Angiodysplasia ** tends to be chronic (angiodysplasia is a small vascular malformation of the gut associated with chronic heart conditions such as heart valve replacement)

Duodenum

Angiodysplasia

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What are the damaging forces that can cause a peptic ulcer?

Under normal circumstances:

Gatric acidity

Peptic enzymes

Injury as a result of:

H.Pylori Infection

NSAIDS

Aspirin

Cigarettes

Alcohol

Gastric hyperacidity

Duodenal gastric reflux

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What are the defensive forces of the upper GI tract?

Surface mucus secretion

Bicarbonate secretion in to mucus

Epithelial regenerative capacity

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What can result in impaired defence mechanisms in the upper GI?

Ischaemia

Shock

Delayed gastric emptying

Host factors

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What is the risk associated with chronic peptic ulcers?

Increased risk of lymphoma and carcinoma

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Where is the most common place for upper GI ulcers?

Duodenal ulcers more common than gastric (75%)

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What are risk factors for upper GI bleed?

Helicobacter pylori
produces urease -> ammonia produced

-> buffers gastric acid => increased acid production

•NSAIDs/Aspirin

prostaglandin production -> reduced mucus and bicarbonate excretion => reduced physical defences

•Alcohol excess

•Systemic illness – “Stress ulcers”

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What may conceal gastric carcinoma?

Gastric ulcers may sit over a gastric carcinoma

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What is Zollinger - Ellison syndrome?

Gastrin - secretin pancreatic tumour - causes recurrent poor healing duodenal ulcers

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What causes bleeding in the case of gastritis and duodenitis?

•Tend to bleed in context of impaired coagulation

Medical conditions
Anti-coagulants (warfarin, rivaroxaban, apixaban, dabigatran, LMWH)
Anti-platelets (clopidogrel, ticagrelor)

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What are the causes of oesophagitis?

Reflux oesophagitis
Hiatus hernia
Alcohol
Bisphosphonates
Systemic illness

More likely to have significant bleeding if on anti-platelet (clopidogrel, ticagrelor) or anti-coagulation (warfarin, rivaroxaban, apixaban, dabigatran)

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What causes an enlarged spleen?

Portal hypertension - this can be as a result of liver cirrhosis

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What causes portal hypertension?

Liver cirrhosis

Blood clots in the portal vein

Blood clots in hepatic veins

Parasitic infection called schistosomiasis, and focal nodular hyperplasia, a disease seen in people infected with HIV

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Where do you find abnormally dilated collateral vessels in portal hypertension?

•Oesophageal (90%)
Gastric (8%)
Rectal and splenic (rare)

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What can cause the bleeds in the varices?

Increases in portal pressure (eg infection/drug use)

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What are the malgnant conditions that can cause upper GI bleeding?

Oesophageal cancer
May have dysphagia /weight loss history
Typically “ooze”

•Gastric cancer

Can present as an ulcer
GU needs interval endoscopy for healing

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When does mallory-weiss tear often present?

Period of wrethcing / vomiting

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Where can angiodysplasia occur in the GI tract?

Anywhere in the GI tract

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What are the colonic causes of acute lower GI bleeding?

Study These Flashcards

Diverticular disease
Haemorrhoids
Vascular malformations (angiodysplasia)
Neoplasia (carcinoma or polyps)
Ischaemic colitis
Radiation enteropathy/proctitis
Inflammatory bowel disease (eg. ulcerative proctitis, Crohn’s disease)

How do you diagnose acute colonic causes of bleeding?

Study These Flashcards

Diagnosis requires flexible sigmoidoscopy or full colonoscopy

What is diverticular disease?

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

What is the difference between diverticulosis and diverticulitits?

* Diverticulosis - presence * Diverticulitis - inflammation

What is the normal prognosis of diverticular disease?

Usually self-limiting (75%)

What are haemorrhoids?

•Enlarged vascular cushions around anal canal

When are haemorrhiods painful?

If thrombosed or external

What are haemorrhoids associated with?

•Association with straining/constipation/low fibre diet

What is treatment of haemorrhoids?

•Treatment is elective surgical intervention

What is treatment of angiodysplasia?

Argon therapy

What are the common types of colonic neoplasia?

•Colonic polyps or carcinoma

Does colonic neoplasia cause life threatening bleeding?

Rarely

Which part of the colon does ischaemic colitis normally affect?

Descending/sigmoid colon

What are complications of ischaemic colitis?

Gangrene and perforation

How does ischaemic colitis normally present?

Crampy abdominal pain, usually self-limiting More comon in those over 60

What radiotherapy treatment might cause radiation proctits?

Cervical cancer Prostate cancer

What is treatment of radiation proctitis?

- APC - Sulcrafate enemas - Hyperbaric oxygen

What are the causes of small bowel bleeding?

Meckel's diverticulum Small bowel angiodysplasia Small bowel tumur /GIST Small bowel ulceration (NSAID associated) Aortoentero fistulation - following AAA repair

Whata re the acute lower GI bleeding investigations?

* CT angiogram * Meckel’s scan (Scintigraphy) * Capsule endoscopy * Double balloon enteroscopy

What is diagnostic for meckel's diverticulum?

•Nuclear Scintigraphy is diagnostic

What is meckels diverticulum?

A congenital bulge from the small intestin resulting from the remnant of the vitelline duct

What is management of GI bleeding?

**•A. Airway** **•B. Breathing** **•C. Circulation**: * Wide bored IV access =\> IV fluids, blood transfusion * Urgent blood samples to lab: FBC, UE, LFT, Coagulation, blood group and save/ cross match * Blood transfusion if Hb\<7g/dl or ongoing active bleeding * Evidence that transfusing Hb\>10g/dl has worse outcomes * Catheter **•D. Disability** **•E. Exposure** * Withhold/reverse contributory medications as able\* * Vitamin K if on warfarin

What is done to the patient after they are stable from their bleed?

_•Endoscopy once stable – within 24 hours_ •Upper GI endoscopy more likely to have therapeutic options _•Consider CT angiography/interventional radiology/surgical interventions as appropriate_

What is meant by shock?

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

What are the features of shock?

* a high respiratory rate (tachypnoea) * a rapid pulse (tachycardia) * anxiety or confusion * cool clammy skin * low urine output (oliguria) * low blood pressure (hypotension)

What is management of GI bleeding: Peptic Ulcer?

* Proton pump inhibitors * Endoscopy with endotherapy * Angiography with embolization * Laparotomy

What is the risk associated with endoscopy?

Re-bleeding

What are the endoscopic therapy options for peptic ulcer?

_•Injection_ •Adrenaline 1:10000 _•Thermal_ •Contact – “gold probe” _•Mechanical_ •Clip _•Haemospray_ Combination therapy most effective (adrenaline + thermal or clips)

What is the treatment for uncontrollable bleeding endoscopically?

Angiography and embolization Laparotomy

What is the endotherapy for oesophageal varices?

Band ligation Glue injection

What is the endotherapy for gastric and rectal causes of GI bleeding?

Glue injection

Why are patients intubated with presence of varices?

Airway protection

What are other ways of managing varices?

**•IV Terlipressin** Vasoconstrictor of splanchnic blood supply * Reduces blood flow to portal vein, reducing portal pressures * Mortality fell from 32% to 12% **•IV Broad spectrum antibiotics** •Often precipitated by systemic infection **•Correct coagulopathy**

What is management of Varices bleeding when uncontrolled at endoscopy?

Acute GI Bleeding Flashcards

(56 cards)