GI bleeding Flashcards
Causes of UPPER GI bleeding:
Peptic ulcers (gastric, duodenal)
Varices (oesophageal, gastric)
Oesophagitis/ gastritis/ duodenitis
Mallory-Weiss
Oesophageal rupture
Angiodysplasia (incl Duilefoy’s Lesion)
AORTOENTERIC FISTULA (post aortic surgery)
Tumours/ polyps
Bleeding diathesis
Pseudo (naso/oeopharynx) incl posterior epistaxis
Causes of LOWER GI bleeding:
Colitis
—> Ischaemic colitis
—> Radiation
Diverticulitis
Inflammatory bowel disease
Bleeding diverticulum
Meckel’s
Angiodysplasia/ AVM
Polyp/ tumour
Haemorrhoids
What bedside test can help DDx upper vs lower GI bleed?
NGT lavage (10ml saline) + aspirate
Additional causes of PAEDIATRIC GI bleeding:
Meckel’s
Intusussception
Foreign Body (incl. button battery, caustic ingestion)
HUS
HSP
NEC
Glascow Blachford Score:
For upper GI bleeds
If score is 0, can go home and be followed up as outpatient.
*Considers:
- Hb, Urea
- PR, BP
- Syncope or malaena
- Comorbid heart or liver
Indications for urgent gastroscopy in GI bleed:
ie. inpatient
Age >60
Suspected varices
Perforated peptic ulcer
HD instability (syncope, hypoTN, >2 units PRBCs)
Haematemesis
Active PR bleed
Roles of endoscopy in GI bleed:
Locate
Treat
Prognosticate (rebleed risk)
Biopsy
Futile in large PR bleed- need hemicolectomy
MANAGEMENT in massive haematemesis:
PPE
Large, dual IV access and haemostatic resus
NGT and decompress stomach
—> Consider emptying with metoclopramide/ erythromycin
Intubate early
- Prepare for difficult incl. surgical
- Ketamine + fentanyl safe in LD
- Direct laryngoscopy
- 2 large suctions
- Fill first
- HD neutral induction (ketamine)
- Have push dose pressors ready (vasopressin)
Source control:
- Urgent endoscopy
- Interventional radiology
- Varices: Balloon tamponade (Blakemore or Minnesota)
Specific Tx:
- PUD: PPI
- Varices: octreotide/ terlipressin/ vasopressin/ somatostatin, ceftriaxone
Specific management in bleeding PEPTIC ULCER (PUD):
ESOMEPRAZOLE or OMEPRAZOLE
40mg IV daily
—> NO benefit to infusion over bolus
Endoscopy:
- Sclerotherapy
- Adrenaline injection
- Ligation
Other options:
- Embolisation (interventional rad)
- Resection (surgical)
Specific management in bleeding OESOPHAGEAL VARICES:
OCTREOTIDE 50microg IV —> 50microg/hr
—> Reduces splanchnic circ, lowers portal pressures, shunts away
Other options:
Terlipressin 2mg IV
Vasopressin
Somatostatin
Ceftriaxone 1g IV
—> Reduces SBP
Ballon tamponade (once tubed)
—> Sengstaken- Blakemore
—> Minnesota
Endoscopy
- Sclerotherapy
- Banding/ clipping
Other options:
- LIVER SHUNT
—> TIPS procedure or open
Mortality in BLEEDING varices?
30%!
What is the splanchnic circulation?
Arterial supply from aorta to GI organs
These drain to the portal vein
Cirrhosis/ portal HTN will cause backlog to these organs (ie. varices)
Peptic Ulcer Disease (PUD):
Risk Factors:
Aspirin
NSAIDS
Corticosteroids
Alcohol
Smoking
Stress
H. Pylori
Zollinger-Elliston (gastronoma)
Clinical:
Burning, gnawing epigastric pain
Pain worse on EMPTY stomach
RED FLAGS
- Early satiety
- Age >55
- Weight loss
- Anorexia
- Dysphagia
- GI bleed
Management:
- PPI
Plus
- H2 antagonist
- Test for H. Pylori
—> Urea breath test, serology, biopsy
—> Triple: PPI + Clarithro + Amoxy/Metro
- If perforated: triple antis and OT.
Complications
Bleed
Perforation
Erosion/fistulae
Obstruction (oedema, scarring)
Diagnosis in lower GI bleeds:
If non-urgent:
Colonoscopy
- Not in urgent setting: view obscured by blood and stool.
If fresh, active bleed ongoing:
CT angiogram
- 85% sensitive and good localisation
- Must be >0.35 ML PER MIN to be seen.
If clinically stopped or intermittent:
Red Cell Scan
- Just as sensitive
- Detects quite slow bleeds (0.1)
- Imprecise localisation
Angiography not common.
- Needs brisk bleed >0.5ml/min.
BUT
- Allows treatment (embolisation/ local constrictor infusion)
If all else fails:
Pill Endoscopy
- Best for small bowel
Management algorithm for lower GI bleed:
