We divide GI bleeds into upper and lower, what do we use as the boundary?
The ligament of treitz
Which connects the stomach to the junction of duodenum/jejunum
How does an upper GI bleed present?
Depends on the location
- Elevated urea
- Often associated with dyspepsia, reflux & epigastric pain
What causes elevated urea in a GI bleed?
partially digested blood
- > Ammonia
- > absorbed and broken down to urea
Whats the most common cause of upper GI bleeding?
Peptic Ulcer Disease, they can occur in any part of the upper GI tract
Duodenal Ulcers are the most common cause of Upper GI bleeds
Only tend to bleed when theres abnormal clotting
List some other causes of upper GI bleeds?
Varices - Mallory Weiss Tear - Malignancy
Gastric Varices - Malignancy - Dieulafoy - Angiodysplasia
What is angiodysplasia
A small vascular malformation of the gut
Associated with chronic cardiovascular disorders, mainly valvular abnormalities/replacements.
How does a peptic ulcer present?
- Weight loss
- Low urine output
- Large volume Melaena
What are hte risk factors for peptic ulcer disease?
- Alcohol & Smoking
- Past history of liver disease
- Family history of peptic ulcers or H pylori infection
How does a peptic ulcer arise?
An imbalance of damaging forces against defensive forces of the gut wall, either fue to increased damage or impaired defenses:
- H Pylori infection, NSAID, Aspirin, cigarettes, alcohol, gastric hyperacidity, gastric reflux
- Ischaemia, shock, delayed gastric emptying, host factors
What could cause excess gastric acid leading to a peptic ulcer?
Which is a gastrin-secreting pancreatic tumour
When would a case of gastritis or duodenitis or oesophagitis be likely to bleed?
IF theres impaired coagulation:
- Medical Conditions
What the common causes of oesophagitis?
- Hiatus Hernia
- Systemic Illness
What tends to cause oesophageal varices and when are they most likely to lead to life-threatening bleeding?
Portal hypertension which is usually due to liver cirrhosis.
A sudden rise in portal pressure such as an infection or drug use can lead to severe bleeding
What is a mallory-weiss teat and how do we treat it?
A linear tear at the gastroesophageal junction, it usually follows a period of retching or vomiting
Most heal spontaneously but 10% require endoscopic treatment
What is diuelafoys lesion?
A submucosal arteriole becomes large and tortuous before eroding through the mucosa and bleeding into the gut
Most commonly in the gastric fundus
How do most lower GI bleeds present?
- Fresh blood/clots in stool
- Magenta Stools
- Typically painless (no somatic innervation down there)
- More common in advanced age
What are the common causes of a lower GI bleed?
- Diverticular Disease
- Vascular Malformations e.g. angiodysplasia
- Neoplasia e.g. carcinomas or polyps
- Ischaemic Colitis
- Radiation enteropathy/proctitis
- IBD (UC/CD)
How do we diagnose the source of a lower GI bleed?
What is diverticular disease?
Protrusion of the inner mucosal lining through the outer muscular layer forming a pouch
Diverticulosis = presence of disease
Diverticulitis = Inflammation
What are haemorrhoids?
Enlarged vascular cushions around the anal canal they can become very painful if theyre below the dentate line.
Associated with constipation, straining & a low fibre diet
What is ischaemic colitis?
A blockage of one of the vessels supplyig the colon leading to tissue ischaemia.
This results in crampy abdominal pain and is usually self-limiting.
However it can be complicated by gangrene or perforation.
Hw does ischaemic colitis appear on endoscopy?
The mucosa is swollen and dusky blue
What causes radiation proctitis and how does it present?
A previous histroy of radiotherapy, usually for cervical cancer or prostate cancer.
Crescendo rectal bleeding
How do we treat radiation proctitis?
= Argon Plasma Coagulation - An endoscopic procedure
= Sulcrafate Enemas
= Hyperbaric O2
Common small bowel causes of GI bleeds?
- Meckel’s Diverticulum, gastric remnant mucosa
- ulceration associated with NSAIDs
- Aortoentero fistula
What investigations can we do if we suspect a bleed to be from a small bowel source?
- CT angiogram
- Meckels Scan (scintigraphy)
- Capsule enterography
- Double balloon enteroscopy
How do we classify shock, particularly the haemorrhagic subtype?
Classified into 4 stages The haemorrhagic subtype is characterized by: - Tachycardia - Tachypnoea - Anxiety/confusion - Cool clammy skin - Oliguria (low urine output) - Hypotension
How do stratify risk in an upper GI bleed?
Glasgow-Blatchford bleeding Score. A score >5 indicates >50% risk of needing intervention
Theres no validated system for scoring lower GI bleeds
How do we treat bleeds from a peptic ulcer?
- Angiography with embolization
- Endoscopy with endotherapy
What types of endotherapy are there for a peptic ulcer
- Adrenaline injection
- Thermal contact with a “gold probe”
- Mechanical Clip
Combination is most effective, the best is adrenaline with clips or thermal contact
What forms of endotherapy are there for varices?
- Band Ligation
- Glue Injection
Other than endotherapy how else do we treat varices?
- IV Terlipressin
A vasocontricter of splanchnic blood supply which reduces portal venous flow lowering portal pressure
- IV Broad spectrum antibiotics if theres a systemic infection
How do we respond to uncontrolled variceal bleeding?
A temporary Sengstaken-Blakemore tube. It includes a gastric & oesophageal balloon to compress the veins.
Then put in a transjugular intrahepatic porto-systemic shunt. Connects portal & hepatic vein with liver to lower portal pressure
What can cause the appearance of melaena?
Bismuth containing products e.g. pepto-bismol or iron supplements can make the stools dark or black
What is haematochezia?
Passage of fresh or unaltered blood per rectum
Vs haematemesis which is from mouth
Vs Maelana which is thick sticky dark faeces containing partially digested blood
Epigastric discomfort, may be exacerbated by eating.