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Flashcards in GI Bleeding Deck (24):
1

Cases of GI Haemorrhages a year

8/10,000

2

Signs of a GI Haemorrhage

HMS HO

 

H - Haematemesis

M - Melaena

S - Syncope and blood loss

 

H - Haematochezia 

O - Occult, iron deficiency

3

After what time in the gut does blood turn into melaena

>14 hours

4

Where would the bleeding have to be in the gut to get melaena?

Proximal colon/Upper GI

If upper GI negative examine proximal colon

5

Where would you have to have bleeding for Haematochezia to occur?

Lower GI

6

CASE:

67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission

PMH
15 year history of rheumatoid arthritis
Angina on exertion.


Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN

 

What do you need to know from the history?

Previous episodes
Previous surgery eg for PU (peptic ulcer) disease
Known varices or chronic liver disease
h/o dyspepsia, abdo pain, vomiting
Associated conditions: cirrhosis
                                         malignancy
                                         IBD   etc

 

Family history:  of bleeding conditions
Drug history:     aspirin/ NSAIDs
       H2receptor antagonists
       Proton pump inhibitors
       Warfarin
Alcohol / smoking history

7

CASE:

67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission

PMH
15 year history of rheumatoid arthritis
Angina on exertion.


Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN

What would you look for on examination?

BP,  Pulse
Stigmata of chronic liver disease
Lymphadenopathy
Abdo mass or tenderness
Hepatomegaly/ splenomegaly
PR
Hereditary haemorrhagic telangiectasia (HHT)
- Genetic Vessel forming condition
Acanthosis nigricans – darker skin in patches

8

CASE:

67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission

PMH
15 year history of rheumatoid arthritis
Angina on exertion.


Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN

 

How are you going to treat her in A+E?

“replace vascular volume as fast as it was lost”

Large venflons
CVP line if:  hypotensive >60 years old
          rebleed going to theatre
           >4 units transfusion
Haemaccel, gelofusine ;  packed cells
O2
Check  Hb*
               clotting screen
                X-match
                U+E

*don’t forget Hb may be normal after a rapid bleed if haemodilution has not occurred
 

Monitor:

BP:                    keep systolic >100mmHg
CVP:                 5-10 cm H2O
Urine output:    >1ml/Kg/hr
Hb:                   >10g/dl
Platelets; clotting; Ca++: correct if necessary

9

CASE:

67 year old lady
Admitted to A+E
Collapsed in the toilet
4 weeks of intermittent epigastric pain
2 day history of haematemesis
Had melaena x2 on the morning of admission

PMH
15 year history of rheumatoid arthritis
Angina on exertion.


Drugs
Has been taking an NSAID regularly for several years recently changed to diclofenac
GTN spray PRN

What investigations would you arrange?

Postural hypotension  (>15mmHg fall)

Tachycardia  (>100)             = blood vol loss
    Vasoconstriction                          5 – 10%

Recumbent hypotension  
             (<100mmHg)               = blood loss vol
    Shock                                             30%+

 

Check  Hb*
               clotting screen
                X-match
                U+E

*don’t forget Hb may be normal after a rapid bleed if haemodilution has not occurred

 

BP:                    keep systolic >100mmHg
CVP:                 5-10 cm H2O
Urine output:    >1ml/Kg/hr
Hb:                   >10g/dl
Platelets; clotting; Ca++: correct if necessary
 

10

How do you asses the risk of GI Haemorrhage?

ROCKALL SCORE

Initial risk score  final risk score
0                          0.2%                     0.0%
1                         2.4%                      0.0%
2                            5.6%                       0.2% 
3                              11.0%                     2.9%
4                             24.6%                  5.3%
5                           39.6%                      10.8%
6                    48.9%                     17.3%
7                           50.0%                  27.0%
8+          41.1%

A image thumb
11

Causes of upper GI Haemorrhage?

Peptic Ulcer       50%

DU                     30%
GU     20%
Erosions      10-20%
Mallory weiss tear     5-10%
Varices    5-7%
Oesophagitis   5%
Cancer     4%
Stomal ulcer    3%
Rare, other    5%
Undiagnosed   5%

12

Hp eradication therapy

Proton pump inhibitor bd
+ 2 of 3 antibiotics
Amoxycillin 1g bd    }
Metronidazole 400mg bd     }   1 week
Clarithromycin 500mg bd   }

About 85-90% eradication rate
Re-infection rate ~ 1%/ year
 

13

Haemostatic therapy of Peptic ulcer?

Coagulation
Injection
Laser therapy

14

Why does re bleeding after injection therapy occur for PU?

Occurs in 10-20%
Greatest risk in first 48 hours

Overt bleeding – haematemesis, melaena
BP and pulse
CVP
Hb  >2g within 24 hours

If in doubt consider repeat endoscopy

15

Stigmata of Haemorrhage?

A image thumb
16

What is this?

A image thumb
17

When should you give  a person with PU surgery?

Exsanguinating
Rebleeding
Continued active bleeding at endoscopy
Transfusion for volume replacement:
<60 yrs  >8 units/ 24 hours
     >12 units/ 48 hours
>60 yrs  > 4 units/ 24 hours

18

Management plan for PU?

A image thumb
19

Pathogenesis of Oesophageal varices?

Up to 50% of patients with cirrhosis or previously documented varices and acute upper GI bleed are bleeding from a non-variceal source
therefore endoscopy required to determine site.

Mortality 40% with each episode
Overall mortality 60% at 2 years
 

A image thumb
20

Management of Oesophageal Varices?

Fluids (colloid)  AVOID SALINE
Transfusion
Platelets and FFP
Vitamin K
lactulose

 

Sclerotherapy

Control of bleeding achieved in 70-95% of patients
Needs to be followed by banding or repeated sclerotherapy
30% will rebleed before varices have been obliterated
Once obliterated, in alcoholics, they probably do not recur if patients stops drinking

 

Both paravariceal and intravariceal injection techniques have been
recommended. Regardless of the location of the external puncture, the depth of
needle penetration may be difficult to control and may range from intravariceal
to submucosal, or into the muscular layer, the latter perhaps predisposing to
deeper ulceration (panel A). The preferred technique is for injections of 1 to 2
mL of sclerosant into the varix starting as distally in the esophagus as
possible (near or just below the esophageal-gastric junction) and in a
circumferential route. Injections are then repeated 2 to 5 cm more proximally
(panel B). The total volume of scleroscent should not exceed 20 mL per session,
above which rate the incidence of complications may increase. No particular
sclerosant has emerged as consistently superior (sodium tetradecyl, ethanolamine
oleate, absolute ethanol, and sodium morrhuate are agents available in the 

21

What is a Variceal band ligation?

Endoscopic placement of bands around oesophageal varices.
Effective at stopping bleeding in ~90%
Needs to be repeated over weeks/months to obliterate varices

22

What is Vasopressin?

Reduces portal venous pressure
20u in 100ml 5% dextrose in 10 minutes
Or infuse 0.4u/min up to 2 hours

S/E: abdominal pain
    facial pallor
         coronary vasoconstriction
         hepatic A blood flow liver necrosis
 

23

Name 2 Somatostatin analogues

octreotide
Terlipressin

Reduce portal pressure
but fewer side effects than vasopressin
 

24

What is a Sengstaken tube?

4 lumen tube
1. Gastric balloon
2. Oesophageal balloon
3. Gastric aspiration
4. Oesophageal aspiration