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General surgery Miscellanous > GI Bleed > Flashcards

GI Bleed Flashcards

1
Q

Most common kind of GI bleed

A

Upper (80%)

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2
Q

How GI bleeds are classified

A

According to location, ligament of Treitz

Ligament of Treitz attaches to the third and fourth parts of the duodenum and the duodenojejunal flexure at the level of the inferior border of the first lumber vertebra

Proximal is UGIB
Distal is LGIB

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3
Q

Causes of UGIB

A

Classify as non variceal(80%) and variceal

Non variceal
- PUD (gastric and duodenal)
- Mallory Weiss syndrome
- Gastritis
- Oesopahigits
- Tumours (benign or malignant)

Variceal
- Gastroiesophageal varices
- Hypertensive portal gastropathy

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4
Q

Presentation of UGIB

A

According to severity of bleed,

Inspection
Range from alert to confused to comatose
Cardio respiratory distress, MM pale and dry, blue fingertips
Tachypneic, tachycardia, widened pulse pressure, hypotensive
No urine production
Haematochezia, haematoemesis, coffee grounds in emesis

Palpation
Cold and clammy extremities
Abdominal pain (epigastric if PUD or gastritis, RUQ if haemobilia,)

DRE melena

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5
Q

What is melena

A

Black, tarry, foul smelling stools need at least >50mL of blood to present with melena.

Due to gastric acid degradation, and action of digestive enzymes and bacteria in small intestine

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6
Q

Distinguish melena from iron supplements greenish stool with this test

A

Guaiac faecal occult blood test
(Negative in iron supplement green stained stool)

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7
Q

Presentation of LGIB

A

According to severity of bleed,

Inspection
Range from alert to confused to comatose
Cardio respiratory distress, MM pale and dry, blue fingertips
Tachypneic, tachycardia, widened pulse pressure, hypotensive
No urine production

Palpation
Cold and clammy extremities
Abdominal pain (LLQ for diverticulitis)

DRE bright red blood per rectum

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8
Q

Causes of LGIB

A

Vascular
- Angiodysplasia
- Diverticula
- Mesenteric ischaemia
- Hameorrhoids

Tumour (benign and malignant)

Trauma
- Anorectal fissure

Inflammatory
- UC

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9
Q

Risk factors for bleeding

A

Bleeding disorders
- platelet dysfunction or thrombocytopenia
- clotting factor deficiency

Drugs
- heparin
- warfarin
- aspirin
- selective serotonin reuptake inhibitors

Disseminated intravascular coagulation

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10
Q

What is an angiodysplasia

A

Degenerative lesions of blood vessels in submucosa of intestine that lead to progressive vasodilation and bleeding when submucosa eroded

Common to right side of colon (caecum)

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11
Q

Angiodysplasia appearance on colonoscopy

A

Red stellate lesion with surrounding rim of pale mucosa

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12
Q

Collection of dilated venues along atrium appearing as red streaks in a longitudinal fashion and giving antrum a watermelon appearance

A

Gastric arterial vascular ectasia

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13
Q

What is Dieulafoys lesion

A

Vascular malformation in stomach within 6cm of gastro oesophageal junction

Unusually large vessels 1-3mm found in gastric submucosa which tend to bleed with erosion of the mucosa

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14
Q

One cause of massive UGIB

A

Variceal haemorrhage
- usually at distal 3-5cm of oesophagus
- up to 1-2cm in size

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15
Q

Erosion of pancreatic pseudocyst in splenic artery
Presents with abdominal pain and haematochezia

A

Haemosuccus pancreaticus

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16
Q

Management of UGIB

A

A and B - check airway patency and suction, check breathing, oxygen administration as needed, intubation as needed

C - Check pulse, blood pressure
Site 2 16 gauge IV accesses
Give crystalloid fluids like Ringers lactate 3ml to ever ml of blood loss
If unstable bolus 2L Ringers lacate
Insert Foley catheter

Take off bloods for
*complete blood count
*Urea and electrolytes
*Platelets, prothrombin time, partial thromboplastin time, liver function tests
*Group and cross match

Locate site of bleeding - pass nasogastric tube, endoscopy - oesophagogastroduodenoscopy

17
Q

Endoscopic interventions for GIB

A

Epinephrine
Electrocautery
Sclerotherapy
Clips

18
Q

Management of LGIB

A

A and B - check airway patency and suction, check breathing, oxygen administration as needed, intubation as needed

C - Check pulse, blood pressure
Site 2 16 gauge IV accesses
Give crystalloid fluids like Ringers lactate 3ml to ever ml of blood loss
If unstable bolus 2L Ringers lacate
Insert Foley catheter

Take off bloods for
*complete blood count
*Urea and electrolytes
*Platelets, prothrombin time, partial thromboplastin time, liver function tests
*Group and cross match

Locate site of bleeding - colonoscopy

19
Q

GIB surgery indications

A

Haemodynamically unstable despite vigorous resuscitation
Prolonged bleeding requiring >3-6 units PRBCs
2 failed endoscopic interventions to stop bleeding
Hypovolemia shock

20
Q

Detects .1ml/min blood flow but is the LEAST ACCURATE in localizing site of bleed

A

Radionuclide scan technetium 99

21
Q

Detects blood flow .5 - 1ml/min usually used to localize bleeding site in ongoing haemorrhage

A

Mesenteric angiography
Traditional angiogram

22
Q

Therapeutic advantages of traditional angiogram

A

Vasopressin infusion
Embolization (gelatin infusion or coils)
No bowel prep needed

Ct angiogram is NOT THERAPEUTIC

23
Q

Management for Diverticular disease and angiodysplasias bleeding

A

Endoscopic - epinephrine, electrocautery, sclerosant or clips
Conventional Angiography - vasopressin or embolization
Surgery - if other measures fail, surgical resection

24
Q

Ct findings of Mesenteric ischaemia

A

Thickened bowel wall

25
Q

Colonoscopy finding of Mesenteric ischaemia

A

Oedema, haemorrhage and demarcation between normal and abnormal mucosa

26
Q

Mesenteric ischaemia management

A

Bowel rest
IV antibiotics
Usually self limiting (85%)

Surgery (15% due to ischaemia and gangrene)

27
Q

Causes of Mesenteric ischaemia

A

CV disease (myocardial infarction, atrial fibrillation, congestive heart failure)
Recent vascular surgery
Vasculitis
Hyper coagulable states
Medication

28
Q

The stage of shock where there is loss of 15% of total body blood volume, elevated heart rate, patient is mildly anxious, but no change in RR, BP, or pulse pressure

A

First stage of shock

29
Q

What is the third stage of shock

A

Loss of 30% to 40% of total blood volume (1500 mL to 2000 mL)
Heart rate significantly elevated (>120 BPM)
Respiratory rate (30-40)
Decrease in blood pressure and pulse pressure
Urine output declines
Capillary refill >2sec
Anxious or confused

30
Q

Stage 2 of hypovolemic shock

A

Loss of 15-30% total body volume (750-1500ml)
Elevated HR >100 and RR 20-30
Decrease in blood pressure and pulse pressure
Decrease urine output
Cap refill >2sec
Mildly anxious

31
Q

Stage 4 in hypovolemic shock

A

Loss of over 40% total body blood volume (2L)
Heart rate at 140
Hypotensive and narrow pulse pressure less than 25
Tachypneic >35
No urine
Cap refill >3sec
Confused or lethargic

General surgery Miscellanous (3 decks)

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