Acute GI bleeding

Question 1

In terms of GI bleeding - when is it considered Upper GI or lower GI?

Answer 1

Upper GI

• bleeding from oesophagus, stomach or duodenum
• (proximal to ligament of Trietz)

Lower GI

• bleeding from jejunum, ileum, colon
• Distal to ligament of Trietz

Question 2

What are the cardinal features of upper GI bleeds

Answer 2

Haematemesis

Melaena - Upper GI means black, tarry stool

Elevated urea - from digestion of haem

Question 3

What are the main features of Lower GI bleeds?

Answer 3

Stool containing fresher blood/clots - usually magenta in colour

Normal urea - as less digestion of haem

Question 4

How do upper and lower GI bleeds differ symptomatically?

Answer 4

Upper GI:

• Tends to be more overt (symptomatic)
• Haematemesis/vomiting
• Dyspepsia, reflux, epigastric pain

Lower GI:

• Typically painless

Question 5

What are the common causes of Upper GI bleeds?

Answer 5

Peptic ulceration (most common)

Infection (oesophagitis, gastritis etc)

Many causes specific to area (oesophagus, stomach, doudenum)

Question 6

What oesophageal problems can cause Upper GI bleeding?

Answer 6

Oesophageal ulcer

Oesophagitis

Oesophageal variceal rupture/bleeding

Mallory Weiss tear

Oesophageal Malignancy

Question 7

What problems in the stomach can cause bleeding?

Answer 7

Gastric ulcer

Gastritis

Varices

Malignancy

Angiodysplasia

Portal hypertensive gastropathy

Question 8

What problems in the duodenum can cause bleeding?

Answer 8

Duodenal ulcer

Duodenitis

Angiodysplasia

Question 9

Variceal bleeding is one of the causes of upper GI bleeding.

Why might it occur?

Answer 9

Variceal bleeding can occur secondary to portal hypertension

Usually due to liver cirrhosis (so associated with alcohol abuse etc)

Question 10

What is Diuelafoy?

Answer 10

Submucosal arteriolar vessel eroding through mucosa

occurs in Gastric fundus - and is rarer cause of upper GI bleeding

Question 11

What is angiodysplasia?

Answer 11

Vascular malformation that can occur anywhere in GI tract (thus can cause upper/lower GI bleeds)

Fairly uncommon cause of bleeding - quite often occult

Associated with heart valve replacements

Question 12

Give an overview of the investigations for GI bleeding.

Answer 12

Upper GI endoscopy

• most important investigatory tool - is both diagnostic and therapeutic

Bloods

• Important to check Haemoglobin, urea & electrolytes, liver biochemistry and coagulation screen
• more on another card

Question 13

What are the causes of acute lower GI bleeding?

Answer 13

Diverticular disease

Haemorrhoids

Angiodysplasia (and other vascular malformations)

Neoplasia (or polyps)

Ischaemic colitis

Radiation enteropathy/proctitis

IBD

Question 14

How is diagnosis of the causes of lower GI bleeding made?

Answer 14

Requires flexible sigmoidoscopy or full colonoscopy

Question 15

What is diverticular disease?

Answer 15

Protrusions of the inner mucosal lining through the outer muscular layer forming pouches

Diverticulosis = presence of pouches

Diverticulitis = inflammation

Question 16

What are haemorrhoids?

Answer 16

Enlarged vascular cushions around anal canal

Become painful when thrombosed or external

Question 17

What patient history is associated with haemorrhoids?

Answer 17

h.o - straining/constipation and low fibre diet

Question 18

Angiodysplasia is a cause of both upper and lower GI bleeds. In lower GI - what can cause angiodysplasia to occur?

Answer 18

Heart valve abnormalities

Antiplatelets and anticoagulants can precipitate bleeding

Question 19

How is lower GI angiodysplasia treated?

Answer 19

Treatment with Argon Phototherapy, medication incl tranexamic acid, thalidomide

Question 20

What is ischaemic colitis, how does it present and what would investigation show?

Answer 20

Ischaemia of parts of colon due to disruption in blood supply

Presents with crampy abdominal pain and lower GI bleeding - typically in patients over 60

Lower GI endoscopy would show dusky blue, swollen mucosa

Question 21

What are the complications of ischaemic colitis?

Answer 21

Gangrene

Perforation

Question 22

How is lower GI bleeding investigated?

Answer 22

Lower GI endoscopy options:

• Proctoscopy
• Flexible sigmoidoscopy
• Colonoscopy (requires prep)

CT angiography - identifies vascular abnormalities; angiodysplasia, ischaemic colitis

Question 23

Acute GI bleeding originating in the small bowel is rare.

Once large bowel and upper GI causes are excluded - this should be investigated.

What are the causes of bleeding from the small bowel?

Answer 23

Meckel’s diverticulum

Angiodysplasia

Neoplasia

Small bowel ulcerations (NSAID associated)

Aortoentero fistulation (following AAA repair)

Question 24

How would you investigate small bowel bleeding?

Answer 24

CT angiography

Meckel’s scan (ie Nuclear Scintigraphy is diagnostic)

Capsule endoscopy

Double balloon enteroscopy

Question 25

Gastrointestinal haemorrhage or severe acute bleeding is an emergency so an ABCDE approach is taken How is _circulation_ managed in GI haemorrhage?

Answer 25

Establish wide bored IV access and administer: * **IV fluids!** * Blood transfusion _{- if in shock / Hb < 7g/dL active bleeding} Urgent blood samples: * FBC, U&Es, LFTs, Coagulation, blood group and save/ crossmatch Catheter Tranexamic acid?

Question 26

After immediate management (patient stabilised) - describe the management of a patient with GI haemorrhage

Answer 26

**Endoscopy** once stable: * aim within 24 hours but sooner if unstable **Withhold/reverse medications** that contributed to the bleeding: * If on warfarin - give Vitamin K or Factor IX complex Consider CT angiography/interventional radiology/surgical interventions as appropriate

Question 27

If a patient with a gastrointestinal haemorrhage continues to actively bleed. What additional management takes place?

Answer 27

If a patient has active bleeding which continues, then they should ALSO be given **blood products and surgery** **IV platelets if \< 50,000 platelets (\< 50)** FFP if INR or APTT\* if \> 1.5x normal range Cryoprecipitate if fibrinogen \< 1.5 g/L

Question 28

In gastrointestinal haemorrhage - if the patient has ongoing bleeding then another card talk about how you can give them FFP What was that all about?

Answer 28

_"FFP if INR or ATPP \> 1.5x normal average"_ * FFP - *Fresh frozen plasma* * INR - *International Normalised Ratio* * APTT - *activated Partial Thromboplastin Time* Both INR/ATPP scores higher than normal indicate the patient has impaired clotting ability - which can account for the ongoing bleeding FFP is a fast replacement for blood proteins and coagulation stuff thats been lost

Question 29

What is circulatory shock?

Answer 29

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

Question 30

What signs are present with shock?

Answer 30

Tachypnoea Tachycardia Hypotension Anxiety or confusion Cool clammy skin Oliguria - *l**ow urine output* *Just think how you'd be if you randomly lost a ton of blood*

Question 31

Peptic ulcers are the most common cause of GI bleeding. What options are available for its management when it causes bleeding?

Answer 31

**Proton pump inhibitors** (eg omeprazole) **Endoscopy with endotherapy** Angiography with embolisation Laparotomy

Question 32

What types of endotherapy can be used to treat peptic ulcers that are causing bleeding?

Answer 32

**Combination therapy** - (adrenaline + thermal or clips)

Question 33

If endoscopy reveals a peptic ulcer that is uncontrollably bleeding and has caused UGIB - how is this managed?

Answer 33

Angiography and embolization Laparotomy

Question 34

How are varices managed in the following places: a) Oesophagus b) Stomach (gastric varices) c) Rectum

Answer 34

All managed through **Endotherapy:** a) _Oesophagus_ * Band ligation * Glue injection b) _Gastric_ * Glue injection c) _Rectal_ * Glue injection Patient should be intubated to ensure airway protection

Question 35

If varices are identified as causing UGIB, what non-surgical management is required?

Answer 35

_IV Terlipressin_ * Vasoconstrictor of splanchnic blood supply _IV broad-spectrum antibiotics_ * As variceal UGIB often precipitated by systemic infection _Correct any coagulopathy that patient may have_

Question 36

If variceal bleeding is uncontrolled at endoscopy - what surgical management is indicated?

Answer 36

Sengstaken-Blakemore tube Transjugular intrahepatic porto-systemic shunt