GI Bleeds - Upper and Lower

Question 1

What separates the Foregut from the hindgut? What is another name for it?

Answer 1

Ligament of Trietz or DJ flexure

Question 2

The ligament of Trietz lies on the second part of the duodenum. In Pediatrics and neonatology, what surgical emergency would be this be involved in? Explain.

Answer 2

Volvulus due to the malrotation of the small bowel. It is normally located on the left side but if malrotated, it will be present on the right side (this is the diagnosis of it too)

Question 3

The ligament of Trietz is highly vascularized receiving supply from the oesophageal arteries from the thoracic aorta, the celiac trunk, and the porto-systemic venous anastomosis. One of these blood supplies are greatly involved in PUD. State the branches of the blood supply most involved in PUD?

Answer 3

Celiac trunk branches into the left gastric, common hepatic (which gives of gastroduodenal artery and right gastric) and the splenic artery.
The left gastric and gastroduodenal are most involved in PUD

Question 4

A patient reports Hematemesis. What would you ask further about the emesis? When asking the patient about the color, what information would that give you?

Answer 4

Other than the typical when, how often, HOW MUCH
Coffee-ground or Frank (bright) red.
Coffee-ground emesis indicates limited bleeding whereas frank red indicates ongoing bleeding

Question 5

A patient reports Malaena. How would they describe it to you?
What are the non-GI bleed causes of Malaena?

Answer 5

Black tarry stools (due to digestion of Hb by bacteria in gut)

Spinach, Iron, and Guinness (beer)

Question 6

What are the 4 most common causes of upper GI bleeding? Give 2 others

Answer 6

PUD (gastric or duodenal ulcer)
Gastritis/oesophagitis
Mallory Weiss Tear
Oesophageal Varices

Gastric carcinoma, pancreatitis, Dieulafoy Lesion

Question 7

What is a Mallory Weiss Tear?

Answer 7

Tearing of tissue in the lower oesophagus due to violent coughing or vomiting (including self-induced)

Question 8

What is a Dieulafoy Lesion

Answer 8

Congenital, large submucosal vessel in the absence of ulcers. May rupture causing bleeding

Question 9

What is Dyspepsia

Answer 9

Indigestion => uncomfortable upper abdominal pain

Question 10

What are the clinical features of chronic liver disease? (5) (actual findings on exam)

Answer 10

Jaundice
Ascites
Spider Nevi
Caput Medusae
Hepatomegaly
Gynecomastia
Ecchymosis

Question 11

What are the features of anemia? (5)

Answer 11

Fatigue
syncope
dyspnea/SOB
Chest pain
Pallor
Dizziness

Question 12

What are the features of hemorrhagic shock?

Answer 12

Hypotension (incl. orthostatic)
Tachycardia
altered mental state
Tachypnea

Question 13

QUICK History/Clinical presentation of a patient with an upper GI bleed (up to 10). Good to have a reason for each e.g. rule out or suggestive of a specific diagnosis (included in answer if needed)

Answer 13

Hematemesis/malaena
Hematochezia (fresh bleeding PA)
Abdominal pain (Worse after eating -> PUD/Gastritis vs Duodenal which improves)
Heartburn, reflux, dyspepsia (suggests oesophagitis/ulceration)
Weight loss (PUD avoid eating) + Dysphagia + night sweats (Malignancy)
Features of chronic liver disease (Jaundice, ascites, spider nevi, caput medusae, hepatomegaly, gynecomastia) -> Varices/portal hypertension
Features of Anemia (pallor, fatigue, syncope, SOB/Dyspnea, chest pain) (from blood loss)
!Previous Endoscopy! (iatrogenic)
Medications: Aspirin, warfarin, antiplatelets esp clopidogrel, NSAIDs, Steroids
Features of Hemorrhagic shock: Hypotension (incl. orthostatic), tachycardia, altered mental state, tachypnea (blood loss)

Question 14

You ask a patient with suspected PUD about the pain they have been having. How would you differentiate between a gastric and duodenal ulcer while sticking to the pain?

Answer 14

Gastric is exacerbated by eating and relieved in duodenal
Gastric will have pain 1-2 hours after eating whereas duodenal is 2-5 hours
Does it awaken you at night. Duodenal more likely to wake the patient up

Question 15

What is Angiodysplasia

Answer 15

abnormal tortuous dilated vessels in mucosal and submucosal layers of GI tract

Question 16

What are the Risk factors for PUD?

Answer 16

H. Pylori, NSAIDs, smoking, stress, HTN, increased acid secretion, long-term use of PPI

Question 17

What are malignant ulcers?
What types of cancers are associated with it? (2)

Answer 17

ulceration due to malignancy e.g. skin (melanoma), breast cancers, Head and neck

Question 18

What are the RFs for GI bleed (in general)?

Answer 18

PUD RFs (H. Pylori, NSAIDs, smoking, stress, HTN, increased acid secretion, long-term use of PPI)
Chronic Liver disease (Jaundice, ascites, spider nevi, caput medusae, hepatomegaly, gynecomastia)
Atrial Fibrillation (strong association with embolus, bleeding and post-op)
!Angiodysplasia! (abnormal tortuous dilated vessels in mucosal and submucosal layers of GI tract)
Oesophagitis/gastritis
Malignant ulcers (ulceration due to malignancy e.g. skin and breast cancers)

Question 19

You are asked to perform a physical exam of a patient with a GI bleed (in general). What are your expected findings/what are you looking for?

Answer 19

Vitals: Tachycardia, hypotension, tachypnea, reduced urine output, altered GCS (these are especially if severe
Palpation: Cool clammy skin, !Reduced cap refill, reduced JVP!, Abdominal mass/tenderness/guarding
Features of Chronic Liver disease (Jaundice, ascites, spider nevi, caput medusae, hepatomegaly, gynecomastia)
!!PR exam: Masses, fresh blood, fecal occult, hemorroids, anal fissures, fistulas

Question 20

QUICK: What are your differentials for an upper GI bleed?

Answer 20

By definition upper GI = oesophagus, stomach and duodenum
Oesophageal: Varices, Malignancy, Ulcer, Oesophagitis, Mallory Weiss Tears
Gastric: Varices, Malignancy, Ulcer, Gastritis, Dieulafoy Lesion
Duodenum: Malignancy, Ulcer, vascular abnormalities (aorto-enteric fistula)

Question 21

A patient with an AAA has hematemesis and malaena. What is the cause of upper GI bleeding associated with AAA?

Answer 21

Vascular malformations (aorto-enteric fistula)

Question 22

What bedside test can you perform to determine if the cause of a GI bleed is more likely to be upper or lower GI?

Answer 22

NG tube Aspirate

Question 23

What X-ray would you order when investigating for an upper GI bleed? Why?

Answer 23

Erect CXR to detect perforation (gas goes up => patient must be upright to allow gas to pool under the diaphragm)

Question 24

What techniques may be used to localize bleeding. State in order of specificity

Answer 24

OGD/colonoscopy/sigmoidoscopy
CT angiogram (0.5-1ml/min)
Nuclear technetium (0.1ml/min) but cannot be done in the acute setting

Question 25

What investigations would you conduct on a patient with a suspected upper GI bleed

Answer 25

Bedside: ECG (A.fib RF) + NGT aspirate (distiguish upper vs lower)

Bloods:
FBC w differentials (anemia and platelets), UandE (increased urea:creatinine ratio), LFT (chronic liver disease)
Coag screen (coagulopathy and INR)
ABG - Rule out Ischemia (via lactate)
Group and Cross-match 4 units (good to include, not necessary)

Imaging:
!Erect! CXR
OGD (tears, varices, ulcers, malignancy…) + used in tx
CT/CT angio to localize bleeding source

Question 26

You are in an emergency station and have to reverse coagulation. The patient is on Warfarin. What are your options? State them in the order of escalation

Answer 26

Vitamin K
FFP - Fresh Frozen Plasma
PCC - Prothrombin Complex Concentrate

Question 27

What is Octreotide?

Answer 27

Somatostatin analogue which is used in variceal bleeding to reduce splanchnic blood flow. (Used as 1st line and serves the purpose of terlipressin or vasopressin but this has specific reduced splanchnic blood flow)

Question 28

What is Splanchnic circulation?

Answer 28

Circulation supplying the GI tract, liver, spleen, and pancreas

Question 29

You are treating a patient with a massive variceal bleed. Giving Octreotide and Terlipressin has not stopped the bleeding. What is your next step? Explain

Answer 29

SB tube (Sengstaken-Blakemore) is used. It is an oesophageal and gastric balloon that is inserted. It has several ports with openings at different points (image).
It provides short term Hemostasis but has many complications with rebleeding hence is only used as temporary stabilization
Note: patient must be intubated when using this due to risk of aspiration

Question 30

A patient with tachycardia, tachypnea, pallor and altered mental state has arrived to the emergency department. The patient has a 6 day history of hematemesis and bleeding PA. It is impossible to distinguish between lower and upper GI bleeding in this case and you must be prepared for anything. What is your immediate management plan for all cases?

Answer 30

ABC. You must still state the basic steps you will do in each. Here is just the important points
1) Admit to hospital
2) ABCDE: Send out FBC w/differentials, U&E, CRP, LFTs, and coag profile, ABG
3) NPO for all, NG tube if vomiting, Intubate if GCS 8 or under or if vomiting
4) O2 if in doubt until ABG becomes available (15L 100% O2 via non-rebreather mask)
5) 2x large bore cannulas, IV fluids at 100ml/hr until losses worked out via intake/output chart +/- urinary catheter
6) Type and save, group and hold, Group and cross match 4 units of blood (10 for AAA). If needed give in 1:1:1 aiming for Hb>8 and >10 in CVD
7) Analgesia (Paracetamol, NSAIDS, Morphine/oxynorm/oxycontin)
8) Antiemetics if needed (Ondansetron)
9) Antibiotics: Coamox/pip taz + Gent/Metronidazole
10) DVT prophylaxis (TEDs, Clexane, LMWH)
If >4 units used, activate Major Transfusion protocol

Medications:
1) Correct Coagulation (vit K > FFP > PCC)
2) UPPER GI - PPI: Bolus IV 80mg Omeprazole followed by 40mg BD or IV 8mg/hr for 72hrs if active bleeding
3) IV 1g Tranexamic Acid TDS
4) VARICEAL BLEED: Vasopressin/Octreotide (somatostatin analogue) -> SB tube

Inform: Endoscopy, surgical on call, anesthetist, ICU, theatre (common sense but must include, it looks rly good)

Question 31

When is the Massive Transfusion Protocol activated?
During transfusion, how is the blood administered? (ratio)

Answer 31

The protocol is activated if either
1) >4 units in <1 hour
2) >10units in <24 hours
3) >50% of total body weight in <3 hours

Blood is transfused with a ratio of 1:1:1 of blood, platelets, and FFP (fresh frozen plasma)

Question 32

What scoring systems may be used to assess prognosis of a patient with an upper GI bleed?
What scoring system is used to determine the risk of rebleeding/death in upper GI bleeds?
That same scoring system could be used for another purpose as well. What is it?
What are its components and cutoffs of this scoring system?

Answer 32

Rockall score and Blatchford score
Rock-all score: Age, BP/BPM (shock), Comorbidity, Diagnosis, and Evidence of bleeding
<3 = good prognosis, >8 = bad prognosis
0/1 = OGD on next available listing, 2+ = Urgent OGD

Question 33

A 55 year old patient presents to the ED with a GI bleed and a history of oesophageal malignancy. On examination his vitals were 65bpm and BP of 140/90. How would you assess his prognosis? When would you slot them in for an OGD?

Answer 33

3 due to malignancy for comorbidities
2 due to upper GI malignancy in diagnosis
Total = 5 => Moderate
2+ => Urgent OGD

Question 34

An 82 year old women presents to the ED with a history of CHD and 50 pack-year history. an OGD has shown tears in the distal esophagus and an image produced is shown. On examination her vitals were 120bpm and BP of 110/60. How would you assess her prognosis?

Answer 34

Age >80 => 2
CHD => 2
BPM >100 but systolic BP>100 => 1
Mallory Weiss Tear => 0
Spurting vessel => 2
Score = 7 therefore moderate prognosis

Question 35

A 70 year old gentleman presents to the ED with PUD. He has a history of Alcoholic liver disease. On OGD adherent clots were found in the stomach. On examination, his vitals were 160bpm and BP 90/50. How would you assess his prognosis?

Answer 35

Age 60-79 => 1
Liver disease => 3
Systolic BP<100 => 2
PUD => 1
Adherent clot => 2
Score = 9 => Bad prognosis

Question 36

What OGD/colonoscopy techniques may be utilized to stop/control bleeding? (especially OGD ofcourse)

Answer 36

Adrenaline injection
Heat probe coagulation (thermal coag)
Argon plasma coagulation
Sclerotherapy (thrombosis due to injection of sclerosant agent)
Banding of varices

Question 37

A patient with Variceal bleeding. He has a history of having large tortuous veins in the esophagus. ABCD assessment has already been completed and the patient is somewhat stable but the bleeding persists. What is your management plan and future escalations for this?

Answer 37

1) OGD with techniques (adrenaline thermal coag, argon plasma…)
2) Angiography with vasopressin injection and/or transcatheter embolization
3) TIPS (transjugular Intrahepatic Portosystemic Shunt)
4) Surgery - Laparotomy

Question 38

What are the indications for surgery for each lower and upper GI bleeds?

Answer 38

In both, this is the last resort
Upper: >6-8 units given <24 hours and still hemodynamically unstable
Lower: >4–6 units given <24 hours and still hemodynamically unstable

Question 39

Define Lower GI bleeding

Answer 39

Abnormal hemorrhage into lumen of bowel from source distal to the ligament of Treitz.

Question 40

Give 2 examples of Anorectal disease

Answer 40

Hemorrhoids, anal fissure, fistula

Question 41

The colon is the source of 95% of lower GI bleeds whereas the small bowel is only responsible for 5%. What are your differentials for a lower GI bleed for both the Colon (6) and Small intestine (4)

Answer 41

Colon: Diverticular disease (40%)
Ischemia (10%)
Anorectal disease => hemorrhoids, anal fissure, fistula (10%)
Malignancy (10%)
Other (15%): IBD, Infectious colitis, Polyps, Radiation colitis/proctitis

Small bowel: Angiodysplasia, Crohn’s, Meckel’s diverticulum, Aortoenteric fistula (AAA complication), Ulcers/erosions

Question 42

QUICK History/Clinical presentation of a patient with a lower GI bleed (up to 8)

Answer 42

Malaena vs Hematochezia (fresh bleeding PA)
Painless bleed (diverticular disease) vs Painful bloody diarrhea (IBD)
Tenesmus (IBD)
Weight loss + night sweats (Malignancy)
Features of Anemia (pallor, fatigue, syncope, SOB/Dyspnea, chest pain) (from blood loss)
!Previous colonoscopy/sigmoidoscopy! (iatrogenic)
Medications: Aspirin, warfarin, antiplatelets esp clopidogrel, NSAIDs, Steroids
Features of Hemorrhagic shock: Hypotension (incl. orthostatic), tachycardia, altered mental state, tachypnea (blood loss)

Question 43

What investigations would you conduct on a patient with a suspected lower GI bleed

Answer 43

Bedside: ECG (A.fib RF) + NGT aspirate (distiguish upper vs lower)

Bloods:
FBC w differentials (anemia and platelets), UandE (increased urea:creatinine ratio), LFT (chronic liver disease)
Coag screen (coagulopathy and INR)
Group and Cross-match 4 units (good to include, not necessary)
ABG - Rule out Ischemia (via lactate)

Imaging:
Colonoscopy/Sigmoidoscopy(tears, varices, ulcers, malignancy…) + used in tx
Note: only effective in mild/moderate bleeding because too much blood to see in severe bleeding
CT/CT angio to localize bleeding source

Question 44

A patient with painless hematochezia arrives to the ED. ABCD assessment has already been completed and the patient is somewhat stable but the bleeding persists. It is confirmed to be a lower GI bleed. What is your management plan and future escalations for this?

Answer 44

Once ABCD assessment has been completed
1) Therapeutic Colonoscopy employing same technique as OGD
2) Mesenteric Angiography employing Vasopressin injection or transcatheter embolization
3) Surgery if hemodynamically unstable with >4-6 units of blood given in <24hrs

Question 45

A patient with Hematochezia cannot have the source localized even with CT angiogram and bleeding is ongoing despite all efforts to treat. Upper GI bleeding has been ruled out via OGD. 5 units of blood have been given to the patient so far since admission 16 hours ago
What can you do to try and localize the source of the bleeding once all else has failed?
With all other treatment options failed (therapeutic colonoscopy, mesenteric angiography vasopressin injection, and embolization), If the source is now localized, what is your management plan?
If the source is still not localized, what is your management plan?

Answer 45

After OGD and Ct angio has failed and the patient is not in an acute setting, nuclear technetium can be used

After all other treatment options have failed and the patient has received >4-6 units of blood (6-8 in upper) in <24 hours => hemodynamically unstable, surgery is the next step
If bleeding source is localized => Resection of bleeding segment
If not localized => Total colectomy with ileoanal anastomosis

Question 46

Why is omental wrapping used for large tears as oppose to pressure and suture used in small tears?

Answer 46

Omental wrapping prevents herniation

Question 47

What type of beta blockers would be used in the treatment or variceal bleeding? Give the best example.

Answer 47

Non-selective. It is also used to prevent what causes this which is cirrhosis and portal hypertension.
E.g. Propanalol