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

What 2 arteries are most involved in PUD?

Answer 3

The left gastric and gastroduodenal are most involved in PUD

Question 4

Spinach, Iron, and Guinness (beer) are known for

Answer 4

Black tarry stools/may mimic malena

Question 5

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

Answer 5

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

Recent OGD, Gastric carcinoma, oesophageal carcinoma, Dieulafoy Lesion, pancreatitis (very rare if pseudocyst rupture or erosion of a nearby vessel)

Question 6

What is a Mallory Weiss Tear?
Where does this typically occur?

Answer 6

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

Question 7

What is a Dieulafoy Lesion

Answer 7

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

Question 8

What is Dyspepsia

Answer 8

Indigestion => uncomfortable upper abdominal pain

Question 9

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

Answer 9

Jaundice
Ascites
Spider Nevi
Caput Medusae
Hepatomegaly
Gynecomastia
Ecchymosis

Question 10

What are the features of anemia? (5)

Answer 10

Fatigue
syncope
dyspnea/SOB
Chest pain
Pallor
Dizziness

Question 11

What are the features of hemorrhagic shock?

Answer 11

Hypotension (incl. orthostatic)
Tachycardia
altered mental state
Tachypnea

Question 12

QUICK History/Clinical presentation of a patient with an upper GI bleed (up to 10)

Answer 12

Hematemesis/malaena
Hematochezia (fresh bleeding PA)
Abdominal pain (Worse after eating -> PUD/Gastritis vs Duodenal which improves)
Heartburn, reflux, dyspepsia
Weight loss + Dysphagia + night sweats
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, NSAIDs, Steroids
Features of Hemorrhagic shock: Hypotension (incl. orthostatic), tachycardia, altered mental state, tachypnea (blood loss)

Question 13

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

Answer 13

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
Duodenal is cyclical
Gastric more associated with weight loss and fe anaemia

Question 14

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

Answer 14

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 15

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

Answer 15

Vascular malformations (aorto-enteric fistula)

Question 16

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

Answer 16

Erect CXR to detect perforation

Question 17

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

Answer 17

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

Question 18

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

Answer 18

Bedside: ECG (A.fib RF) + ABG

Bloods:
FBC w differentials (anemia and platelets), U&E (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 19

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 19

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

Question 20

What is Octreotide?

Answer 20

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 21

What is Splanchnic circulation?

Answer 21

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

Question 22

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 22

OGD is the next step but since it is a massive bleed, that would not be suitable. Best course of action is to transfer the patient to theatre and attempt OGD techniques there as anaesthetics are better equipped to manage an emergency and easy to convert to laparotomy if needed. To transfer him to theatre, and SB tube must be inserted
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

Question 23

Why is a patient with an SB tube typically intubated?

Answer 23

Intubated to prevent aspiration risk

Question 24

What is an SB tube?
How will you use it? Walk me through it

Answer 24

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

1) Sedate the patient and give analgesia (GA in extreme cases)
2) Intubate patient to prevent aspiration risk
3) Inflate the gastric balloon only and suspend on a 1Kg or 1L bag of saline
3) As a last line measure, inflate the Oesophageal balloon

Question 25

SB tube quick questions: 1) Can an OGD be inserted if a patient has an SB tube? 2) Why do we suspend the SB tube? 3) What is the reason we do not inflate the esophageal balloon 4) What are the top 3 complications of an SB tube?

Answer 25

1) Theoretically yes, realistically wtf 2) To ensure that it will not dislodge and apply pressure on the varices to stop the bleeding 3) Esophageal necrosis 4) Aspiration, Rebleeding, andf oesophageal necrosis

Question 26

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. What is your immediate management plan for all cases?

Answer 26

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 (aim >0.5ml/kg/hr) 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

Question 27

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

Answer 27

Note that this changes based on hospital 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 28

What scoring systems may be used to assess prognosis of a patient with an upper GI bleed?

Answer 28

Rockall score and Blatchford score

Question 29

What is the Rockall and blatchford scoring systems used for? Go through the scoring system, cutoffs etc for the Rockall score.

Answer 29

The blatchford scoring system is used to assess the need for urgent treatment and hospital admission before endoscopy The rockall scoring system is used after endoscopy to evaluate the risk of rebleeding and mortality and can also be used pre-endoscopy to triage whether an OGD needs to be performed urgently or not. Rock-all score: Age, BP/BPM (shock), Comorbidity, Diagnosis, and Evidence of bleeding <3 = good prognosis, >8 = bad prognosis Can also be used to assess triage whether an OGD needs to be performed urgently or not 0/1 = OGD on next available listing, 2+ = Urgent OGD

Question 30

What is the blatchford score used for?

Answer 30

Used to predict need for endoscopic therapy and discharge

Question 31

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 31

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

Question 32

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 32

Rockall score 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 33

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 33

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

Question 34

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

Answer 34

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

Question 35

What is the therapeutic component for CT angiography (similar concept to OGD techniques)

Answer 35

clip/coil/sclerose identified bleeding vessel

Question 36

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 36

1) Octreotide 2) OGD with techniques (adrenaline thermal coag, oesophageal banding...) 3) Angiography with vasopressin injection, clip/coil/sclerose and/or transcatheter embolization 4) TIPS (transjugular Intrahepatic Portosystemic Shunt) 5) Surgery - Laparotomy

Question 37

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

Answer 37

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

Question 38

Define Lower GI bleeding

Answer 38

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

Question 39

Give 2 examples of Anorectal disease

Answer 39

Hemorrhoids, anal fissure, fistula

Question 40

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 40

Colon: Diverticular disease (40%) Ischaemic, Inflammatory, infectious, Radiation colitis (30%) Anorectal disease => hemorrhoids, anal fissure, fistula (10%) Malignancy (10%) Polyps!!!!!!!!! (10%) Angiodysplasia (10%) IBD Small bowel: Angiodysplasia, Crohn's, Meckel's diverticulum, Aortoenteric fistula (AAA complication), Ulcers/erosions, Any upper GI cause

Question 41

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

Answer 41

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 42

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

Answer 42

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 43

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 43

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 44

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 With all other treatment options failed (therapeutic colonoscopy, mesenteric angiography vasopressin injection, and embolization), If the source is now localized, what is your surgical management? If the source is still not localized, how will you surgically manage?

Answer 44

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 => adrenaline injection, clip, oversow and ommental patching and finally Resection of bleeding segment If not localized => Total colectomy with ileoanal anastomosis (temporary ileostomy)

Question 45

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

Answer 45

Omental wrapping prevents herniation

Question 46

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

Answer 46

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

Question 47

After a massive Upper GI bleed. What will you send the patient home on?

Answer 47

H.Pylori eradication => triple therapy with PAC500 or PMC250

Question 48

When managing a patient with an upper GI bleed it is important first to determine if the patient is stable or unstable and second to determine if it is a variceal blled or a non-variceal bleed. In what circumstance will you administer a prokinetic? Give me 3 examples What about antibiotics

Answer 48

Prokinetics should be administered if there is a non-variceal bleed to evacuate the blood from the stomach for endoscopy Erythromycin Metoclopramide Domperidone Antibiotics on the other hand should be given to those with a Variceal bleed as they may be decompensated

Question 49

What classification is used to determine the severity of an upper GI bleed based on endoscopy findings? Go through it (not rockall)

Answer 49

Forrest Classification it indicates the risk of rebleeding prognostically Ia - Spurting haemorrhage (2pts on rockall) Ib - Oozing haemorrhage IIa - Non-bleeding visible vessel IIb - Adherent clot (2pts on rockall) IIc - Flat pigmented spot III - Clean base ulcer Remember that the worst is I and best is III

Question 50

When treating an upper GI bleed (OGD) dual therapy is always better than monotherapy. What is meant by dual therapy?

Answer 50

Dual therapy is Adrenaline injection + Thermal or mechanical techniques. (e.g. clip, banding, diathermy) Monotherapy is only one of them. Dual therapy has a reduced risk of rebleeding, reduced need for surgery and reduced mortality

Question 51

Are outcomes better with surgery or IR embolization?

Answer 51

Based on a meta-analysis in the BJS, surgery has generally better outcomes

Question 52

In a patient with a large bleeding duodenal ulcer, which is the most appropriate operation to be performed when endoscopy was unsuccessful in haemorrhage control? What if that fails

Answer 52

Laparoscopy to oversow of the gastroduodenal ulcer via graham patch repair (esp if large to prevent herniation) Then open laparotomy which can include a partial or total gastrectomy/removal of diseased segment

Question 53

What is rectorrhagia?

Answer 53

Fresh Bleeding PA without stools

Question 54

Patient presents with lower GI bleeding and pain specifically on the left side. What are the 2 most likely dx?

Answer 54

Diverticulitis Ischaemic colitis

Question 55

A patient presents with lower GI bleeding and has a history of A.fib. What is the most important question to ask?

Answer 55

are they on anti-coagulants?

Question 56

A patient presents to the ED with a lower GI bleed. What is the name of the scoring system used to determine if the patient should be discharged or admitted? What are the 3 main components in it (very general) How would you interpret the score?

Answer 56

Oakland score is based on 1) Patient factors (age, sex) 2) History and exam findings (previous admission, DRE) 3) Vitals and Hb Score <9 = discharge (which means GP referral for OPD endoscopy and followup) Score 9+ = Admit

Question 57

What transfusion policy is used in both upper and lower GI bleeds? A) Restrictive B) Liberal C) Aggressive

Answer 57

A - Restrictive (dont forget to contact ICU)

Question 58

What is the door to CT angio time in an upper or lower GI bleed?

Answer 58

60 minutes ideally

Question 59

Angiography (not the same as CT angiography which is done first and must be done within 60 minutes if possible) is typically conducted with which arteries for a lower GI bleed

Answer 59

SMA or IMA

Question 60

Unlike an upper GI bleed, a lower GI bleed rarely needs surgery. What are some indications for a lower GI bleed surgery?

Answer 60

1) Haemodynamically unstable despite previous step-ups 2) Bleeding duration >72 hours 3) Transfusion >6-8 units in 24 hours 4) Rebleed after cessation for >24 hours 5) Ischemia 6) Peritonitis