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Flashcards in Acute GI Bleeding Deck (48)
1

What is the ligament of Treitz?

Connects small bowel to the lower part of the greater curvature of the stomach.

This creates a bend in the small intestine which proximally is the ascending duodenum and distally is the jejunum.

2

Where does Upper GI bleeding occur?

Proximal to the ligament of Treitz.
Oesophagus, stomach and duodenum

3

Where does lower GI bleeding occur?

Distal to the ligament of Treitz.
Small bowel and colon

4

What are signs of upper GI bleeding?

Usually fresh haematemesis or ?coffee ground vomiting
Malaena
Dyspeptic Symptoms
Epigastric Pain
NSAIDs, Aspirin, Clopidogrel, Warfarin, Brufen
Endoscopy
Elevated Urea

5

What are the signs of lower GI bleeding?

Usually BUT NOT ALWAYS fresh or altered blood
Age- more common with increasing age
Endoscopy
Normal Urea

6

What is haematemesis?

Vomiting of Blood
Bright red haematemesis = active haemorrhage from the oesophagus, stomach or duodenum

7

What is coffee ground vomit?

Vomiting of brown-black material which is assumed to be blood.

-Recent study using ARI bleeding unit found poor correlation between coffee ground vomit and endoscopic findings
-More suggestive of systemic illness, is associated with poor outcome in >50yrs

8

What is malaena?

Passage of black, tarry, loose stools per rectum
Considered to be partially digested blood

Acute upper GI bleeding
Occasionally from bleeding within the small bowel or right side of colon

9

What is Hematochezia?

Passage of fresh or altered stool per rectum
May be from upper GI cause ("fast transit") or lower GI

10

What are some of the causes of GI bleeding?

Peptic Ulcer (GU/DU) = 44%
Gastritis/Erosions = 26%
Oesophagitis = 28%
Erosive duodenitis = 15%
Varices = 13%
Malignancy = 5%

No cause found = 20%

11

What are the risk factors for peptic ulcer and what are the risk factors similar to?

Helicobacter Pylori
NSAIDs/Aspirin
Alcohol excess
Systemic illness

Similar risk factors for gastritis and duodenitis

12

Whats more common GU or DU?

DU (75%)

Rarely zollinger-ellison syndrome
-Gastrin secreting pancreatic tumour

13

What may gastric ulcers overly?

Gastric carcinoma

14

Give some causes of oesophagitis

Reflux oesophagitis
Hiatus hernia
Alcohol
Biphosphonates
Systemic illness

15

Describe Varices

Secondary to portal hypertension, usually due to liver cirrhosis
Abnormally dilated collateral vessels
Most commonly oesophageal (90%), but also gastric (8%), rectal and splenic
Increases in portal pressure (e.g. infection/drug use) can lead to life threatening bleeding

16

What is a Mallory Weiss Tear?

Linear tear in the lower oesophagus
Follows recurrent retching and vomiting
Bleeding stops spontaneously in 80-90% of patients
Haemodynamic instability and shock may occur in up to 10% of patients

17

What features may you see in an upper GI bleeding history?

Vomiting blood/black fluid
Passing black stools (malaena)
Abdominal pain (PU)
Drugs:
-Anti-platelets (aspirin, clopidogrel, Ticagrelor)
-Anticoagulants (LMWH, Warfarin, Rivaroxiban, Dabigatran)
-NSAIDs (Ibuprofen, Diclofenac)
-Dizzy/collapse
-Poor urine output

18

What are some important clues in the history of upper GI bleeding?

Alcohol excess
Known liver disease
Weight loss
Reflux/dyspeptic history
Medications

19

What investigations would you carry out in Upper GI bleeding?

Full blood count
Urea electrolytes
LFT
Coagulation
Blood group and x match

20

What are you looking for in an upper GI bleeding examination?

Signs of liver disease (varices)
Telangiectasia/cardiac disease (angiodysplasia)
Lymphadenopathy/ hepatomegaly (malignancy)

21

What is the management of upper GI bleeding?

Resuscitation/ Identification of shock
Consider blood transfusion =/- platelets /FFP
Risk stratification
Management of high risk patients in high dependency unit
Early Upper Gi endoscopy once stable
--Endotherapy
--Specific medications
Embolisation or surgery if not possible to control endoscopically

22

What are some additional medical treatments you can include in the management of someone with upper GI bleeding.

Adjuvant to endoscopy:
-Omeprazole
-Terlipressin +/- broad spectrum antibiotics (vatical bleed)

23

What are the high risk factors for UGI Bleed?
(Factors showing severe event)

Age >50
Co-morbidities (Liver, cardiac, respiratory)
Inpatients
Initial presentation with:
-Haematemesis
-Malaena
-Shock
-Collapse
Continued bleeding after admission
Elevated blood urea

24

What is the Rockall Score?

Pre-endoscopic risk assessment in UGIB

Simple and widely validated scoring system
Principally designed to predict death
May also be used to predict rebleeding risk

Based primarily off age, shock and co-morbidities

25

What is the Blatchford score?

Clinical information on admission:
-Hb, urea, Pulse, BP, Syncope, Malaena, Liver & HF

Predicts need for intervention more accurately than Rockall
Useful in deciding when not to do endoscopy

26

How do you manage a bleeding peptic ulcer?

RESUSCITATION
Endoscopy
Endotherapy
PPI
Check helicobacter pylori status
Discontinue causative/ contributory medications

27

When should PPI like omeprazole be given?

Following endoscopic haemostats therapy
After 1 week eradication course for H. Pylori

Non-NSAID users: Discontinue PPI after successful healing of ulcer and H. Pylori eradication
NSAID, Aspirin or COX-2 users: Concomitant PPI therapy

28

What drugs should be discontinued or used with caution in patients with PU or UGIB?

Withhold:
-Oral anticoagulants, Aspirin, NSAIDs acutely

Use with caution:
-Selective Serotonin Reuptake Inhibitors
-A non SSRI antidepressant may be an appropriate choice in such patients

Oral anticoagulants or corticosteroids should be used with caution in patients at risk from GI bleeding, especially in those taking aspirin or NSAIDs

29

Why is everyone so hung up on resuscitation before endoscopy?

Optimum resuscitation is essential before endoscopy in order to reduce the potential cardio-respiratory complication of the procedure.

30

In acute upper GI bleeding when should you aim to get the endoscopy done?

Within 24 hours of the initial presentation where possible

31

What are the endotherapy options in acute UGIB?

Injection: adrenaline
Thermal: Contact or Non-Contact
Mechanical: Haemostatic clips, Band ligation

Combination: Injection + Thermal or Injection + Clips

32

What can you consider if you can't stop an acute bleed endoscopically?

Angiography + embolisation

Laparotomy and resection of infected organ
-Partial gastrectomy

33

How do you deal with a variceal bleed endoscopically?

Oesophageal: Band ligation, Glue injection
Gastric: Glue injection
Rectal: Glue injection

Ideally intubated for airway protection

34

What additional management would you use in a variceal bleed?

IV Terlipressin
-Vasoconstrictor of splanchnic blood supply
---Reduces blood flow to portal vein, reducing portal pressures

IV broad spectrum antibiotics
--often precipitated by systemic infection

Correct coagulopathy

35

How do you deal with an uncontrolled variceal bleed?

Sengstaken-Blakemore tube
-Tamponade to OG junction
-Temporary measure

TIPSS
-Transjugular intrahepatic port shunt

36

What should you do with individuals at high risk of re-bleeding?

TIPS early on

37

What are the major causes of lower GI bleeding?

Diverticular disease
Vascular malformations (angiodysplasia)
Haemorrhoids
Neoplasia (carcinoma or polyps)
Ischeamic colitis
Radiation enteropathy/ proctitis
IBD (e.g. ulcerative proctitis, Crohn's disease)

38

Give a description of diverticular disease from a GI bleed point of view

Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
Diverticulosis = presence
Diverticulitis = Inflammation
Bleeding occurs in 10-20% during the lifetime
Usually self limiting (75%)
Risk of further bleeding

39

What is colonic angiodysplasia?

Vascular malformation (degeneration)
Friable and bleeds easily
May be association with valvular abnormalities
Bleeding often precipitated by anticoagulants/ anti-platelets

Can occur in small bowel also
Treatment with Argon Phototherapy

40

What is ischaemic colitis?

Disruption in blood supply to colon
Presents with crampy abdominal pain
More common in over 60 year olds
Usually self limiting
Complications include gangrene and perforation

41

If colonic causes are not found for bleeding and upper GU has been excluded, what's next?

Need to consider small bowel origin

42

What are some small bowel bleeding causes?

Small bowel angiodysplasia
Small bowel tumour/ GIST
Meckel's diverticulum
Small bowel ulceration
Aortoentero fistulation - following AAA repair

43

How do you investigate (imaging) lower GI bleeding?

CT angiography
Formal angiography
Small bowel capsule enteroscopy
Double balloon enteroscopy

44

What are the blood investigations for lower GI bleeding?

Full blood count
U+E
LFT
Coagulation
Blood group and save x match

45

What is the management of lower GI bleeding?

Colonoscopic haemostatic techniques (adrenaline injections, bipolar coagulation , endoscopic haemoclipping)

Angiography and embolisation

Band ligation for haemorrhoids

Surgery:
-Segmental intestinal resection or subtotal colectomy

46

What are the risk factors for mortality in lower GI bleeding?

Age
Co-morbidity
Inpatients
Initial shock
Drugs : NSIADs and aspirin

47

Describe shock in acute GI bleeding

Shock = circulatory insufficiency resulting in inadequate oxygen delivery leading to global hypo perfusion and tissue hypoxia.

In GI bleeding the shock is most likely to be hypovolaemic
(aka haemorrhagic)

-Tachypnoea
-Tachycardia
-Anxiety or confusion
-Cool clammy skin
-Low urine output (oliguria)
-Hypotension

Patient with normal BP may still be in shock and require resuscitation

48

Where should you send patients who come in with acute UGIB?

Should be admitted, assessed and managed by a dedicated GI bleeding unit