Clinical Topic 2: GI Bleeding Flashcards by Ruksana Begum

What are the two scoring systems used in patients with Upper GI Bleeding?

Blatchford Score

Rockall Score

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When is the Blatchford Score used, what is the range of the scoring, what is assessed and what is a poor score to have?

Used in initial assessments of patients with Upper GI Bleeding

Ranges from 0 to 23

Assessed by Blood urea nitrogen, Hb levels, Systolic BP, HR, melena, hepatic and cardiac disease

High risk of bleeding with score >0

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When is the Rockall Score used, what is assessed and what is a good and poor score to have?

Used after patients have endoscopy for Upper GI Bleeding

Assesses ABCDE:
Age, Blood pressure (Shock),Co-morbidity, Diagnosis, Evidence of Bleeding

Score <3 = good, >8 = high mortality

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What are the NICE Guidelines for Endoscopic treatment for non-variceal Upper GI bleeds?

Do not give adrenaline as a mono-therapy
1. Clips ± adrenaline
2. Thermal coagulation + adrenaline
3. Fibrin/thrombin + adrenaline

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What are the NICE Guidelines for treatment for variceal Upper GI bleeds?

Terlipressin + antibiotics and….

Oesophageal varices: Banding (1st line), TIPS (2nd line)
Gastric varices: Cyanoacrylate (1st line), TIPS (2nd line)

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What is Boerhaave syndrome? What is it usually caused by?

Spontaneous perforation of Oesophagus, usually due to medical instrumentation i.e. Endoscopy

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What is the clinical significance of the Ligament of Treitz (Suspensory muscle of Duodenum)?

Anatomical landmark to differentiate between Upper and Lower GI Bleeding

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What is a Deulefoy’s lesion?

Large tortuous arteriole most commonly in the stomach submucosa that erodes and bleeds

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What is the microbiology of H. pylori, a bacteria which can cause upper GI ulcers

Gram negative, curved rod shaped, helical bacilli

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What is the role of Parietal cells, where are they located, and what can they be influenced by?

Release of HCl, located in the fundus and body, and are influenced by G cells which secrete Gastrin to cause further HCl release by Parietal cells

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What are the common locations of Gastric and Duodenal ulcers?

Gastric: Lesser curve of stomach
Duodenal: After the pyloric sphincter

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What is Zollinger-Ellison Syndrome?

Neuroendocrine gastrinoma located in the duodenum or pancreas, releasing gastrin which simulates Parietal cells to release more HCl causing ulceration

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In Gastric ulcers, which artery may be invaded by an ulcer and cause massive bleeding?

Left gastric artery

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In Duodenal ulcers, which artery may be invaded by an ulcer and cause massive bleeding?

Gastroduodenal artery

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How might a perforated Peptic ulcer cause referred pain?

Air collection under the diaphragm, causing phrenic nerve irritation and referred pain to the shoulder

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How do longstanding duodenal ulcers cause Gastric Outlet Obstruction?

Longstanding oedema and scarring prevents passage of gastric contents

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Why do gastric ulcers cause post-prandial abdominal pain?

Release of HCl due to eating

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Why is duodenal ulcer pain relieved by eating?

Release of Bicarbonate from Brunner glands which neutralises HCl

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Mallory Weiss tears affect which layer of the oesophagus? What kind of tears are they?

Only the mucosa, and longitudinal linear tears

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What is the difference between Mallory Weiss tear and Boarhaave’s syndrome?

Mallory Weiss - only mucosal tear
Boarhaave’s syndrome - full thickness tear, can also hear Hamman’s sign (crunching sounds on auscultation due to pneumomediastinum)

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What is Haematochezia?

Fresh red blood per rectum

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Intussusception commonly occurs in what age group?

Mainly infants, 2/3rds of which before the age of 1. Can also occur in adults

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What is the most common cause of bowel obstruction?

Intussusception

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Which region of the GI tract does Intussusception commonly occur?

Ileocaecal region, where the ileum folds into the caecum

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What is the common leading edge in infants with Intussusception?

Lymphoid hyperplasia, particularly Peyer's patches

What are symptoms of Intussusception?

- Intermittent abdominal pain - Red currant jelly stools - Billous vomiting - Sausage shaped structure in abdomen - Drawing knees up to chest

In imaging, what may be visualised in patients with Intussusception?

Bull's eye, which is the telescoped intestine on end

What are treatment options for Intussusception?

- Barium or air enema - Surgery

What are the common places for Diverticula to form in Caucasian and Asian populations?

Caucasian populations: Sigmoid colon | Asian populations: Right sided colon

What is a true Diverticula and a false (pseudo) Diverticula? Which are most common?

True diverticula are congenital and involve all four layers of the GI wall, whereas false diverticula are acquired and only involve the mucosa and submucosa, but not to the muscularis. False diverticula are more common.

Why do diverticula commonly occur in the sigmoid colon for Caucasian populations?

Sigmoid colon has the narrowest lumen

What two connective tissue disorders increase your risk of Diverticular Disease?

- Marfan's syndrome | - Enlers-Danlos syndrome

What is the name given to a perforated diverticula connecting to the bladder? What are the symptoms?

Colovesicular fistula Symptoms include air and stool content in urine, and recurrent UTIs

What are the symptoms of Diverticulosis?

Intermittent LLQ abdominal pain, bloating, constipation, diarrhoea, mucoid stools

What tests are used to detect H. pylori?

- CLO test from biopsy - Carbon urea breath test - Faecal antigen test - Histology - Culture

Explain the rationale of the Carbon Urea Breath Test to detect for H. Pylori infection

13C-labelled urea drink is fed to patients after an overnight fast. In the stomach the H. Pylori contains urease which breaks down 13C Urea into 13CO2. The 13CO2 travels to the lungs where it is exhaled

What medications can increase the risk of Peptic Ulcer Disease?

NSAIDs Aspirin Bisphosphonates Theophylline

State two conditions which increase your likelihood of peptic ulcer formation

Zollinger-Ellison Syndrome | Multiple Endocrine Neoplasia Type 1 (MEN1)

Why might patients with suspected Peptic Ulcers have false negatives on faecal antigen tests, carbon urea tests and CLO tests? What can be done to avoid this?

Proton pump inhibitor use can mask peptic ulcer disease. Instruct patient to stop taking PPI for 2 weeks before the test is performed

What is the medication regime for treating H. Pylori infection?

3 medications, twice a day, for 1 week (3-2-1) 3 medications are 2 antibiotics and 1 proton pump inhibitor (3-2-1) A + C C + M M + A

What are some non-surgical and surgical treatments for Haemorrhoids?

Non surgical: High fibre diet, Sitz baths, Steroid creams, Pramoxine hydrochloride Surgical: Rubber band ligation, Photocoagulation, Haemorroidectomy

What are some risk factors for the development of Haemorroids?

Severe constipation, portal hypertension, pregnancy, heavy lifting / straining, obesity

What is the significance of the Dentate / Pectinate line?

Internal haemorroids: Above dentate line | External haemorrhoids: Below dentate line

What is the pathophysiology of Haemorroids?

Haemorroidal plexi are veins which are normal structures in the anal canal to help cushion for stool control. They can however become swollen and enlarged and protrude, causing symptoms

What are the symptoms of internal vs external haemorroids?

Internal haemorroids: Painless, feeling of rectal discomfort, mucus discharge, haematochezia External haemorroids: Sudden, severe peri-anal pain, pain on defacation

Where do the upper, middle and lower parts of the external haemorrhoidal plexi drain into?

Upper -> Superior Rectal -> Inferior mesenteric Middle -> Middle Rectal -> Internal iliac Lower -> Inferior Rectal -> Internal pudendal

What are the most common type of Colonic Polyps? What are they caused by? Can they be malignant?

Adenomatous Polyps, caused by a mutation in the APC (tumour supressor gene) on Chromosome 5. Can be malignant if they acquire other mutations in genes such as KRAS or p53

What is the genetic inheritance pattern of Familial Adenomatous Polyposis (FAP)?

Autosomal Dominant

What are the different types of neoplastic and non-neoplastic polyps based on epithelial histology?

Neoplastic: Adenomatous, Serrated (if large), Villous | Non-neoplastic: Tubular, Tubularvillous, Serrated (if small)

What are the different types of polyps based on their elevation from the colonic wall? Which are most neoplastic?

Pedunculated Sessile - most neoplastic Flat

Hamartomatous polyps are associated with what two conditions?

Juvenile Polyposis | Peutz-Jehger's Syndrome

Juvenile Polyposis is associated with a mutation in which gene?

SMAD-4

What is the genetic inheritance pattern of Juvenile Polyposis?

Autosomal dominant

What is the genetic inheritance pattern of Peutz-Jehger's Syndrome?

Autosomal dominant

Peutz-Jehger's is associated with a mutation in which gene?

STK-11

What are some of the steps for resuscitation of a patient with an Acute Upper GI Bleed?

- Atleast two large bore cannula insertion (16-18G) - FBC, U&Es, Clotting, Cross-matching - Arterial / Venous blood gas sampling - Notify duty endoscopist within 1 hour - Place patient on nil by mouth - Implement haemorrhage protocol

What is Angiodysplasia? How is it treated?

Small vascular malformations located in submucosa and mucosa of the lower GI tract. Treated with Adrenaline and APC

CA19-9 is a marker for which disease?

Pancreatic Cancer

CEA is a marker for which disease?

Colorectal Cancer

AFP is a marker for which disease?

Hepatocellular Carcinoma

Bowel obstruction is more common in colorectal cancer of Ascending or Descending Bowel?

Descending Bowel

Ischaemic Colitis is common in which part of the GI tract? Why?

Splenic flexure (1st) and Retrosigmoidal area (2nd) due to watershed areas

What is "Apple Coring" as seen on a Barium enema?

A sign of lumenal narrowing, commonly in Colon cancer of the Descending Colon

What is the difference between the outer layers of Intraperitoneal and Retroperitoneal organs?

Intraperitoneal organs - Serosa | Retroperitoneal organs - Adventitia

What is the mechanism of action of Proton Pump Inhibitors?

H+/K+/ATPase Inhibitor

CA125 is a marker for which disease?

Ovarian, Endometrial, Fallopian tube Cancer

A patient with a large rectal bleed and is haemodynamically unstable, has a diagnosis of what until proven otherwise?

Upper GI Bleed

What is the first-line investigation for Ischaemic Bowel Disease?

Lactate

Clinical Topic 2: GI Bleeding Flashcards

(68 cards)