GI Drug Loss Flashcards
(25 cards)
What is the
- Incidence
- Mortality
- Chance of re-bleed
For acute GI bleeds
- 100 per 100,000 population each year
- 14% (in specialised bleeding unit=5%
- 20%
What are the sites of GI bleed?
Upper GI bleed (70%) – oesophagus, stomach, duodenum Small bowel GI bleed (rare <1%)
Large bowel GI bleed (common 30%)
What is the clinical presentation of acute GI bleed?
Haematemesis – throwing up blood
Melena – digested blood in stools
Shock
Per rectum (Pr) bleed – fresh blood in stools
What is the clinical presentation of chronic GI bleeds?
Anaemia, iron-deficient (microcytic)
Positive faecal occult blood (FOB) test – picked up in bowel cancer screening test, detects
presence of blood in stools
What are the causes of upper GI bleeding?
Oesophageal/oesophagus (10%)
Peptic ulcer (50%)
Gastroduodenal erosions (10%)
Varices (10%) - dilated veins, variceal bleed occurs at a much lower pressure than an arterial bleed
No cause found (20%)
What are the causes of GI bleed in the small bowl?
Jejunal/ileal diverticula
What are the causes of GI bleed in the large bowel?
Angiodysplasia (40%)
Diverticular disease (40%)
Carcinoma/Polyp (<5%)
U.C/Crohn’s (<5%)
Haemorrhoids/Fissure/Fistula – haemorrhoids are the most common, you see blood when you wipe
What is the management of chronic GI bleeds?
History
Clinical examination
Abdominal examination
Pr examination
Rigid sigmoidoscopy
Blood tests including FBC, U&E, haematinics
Endoscopy/colonoscopy/CT colonography
Capsule endoscopy/CT or MR small bowel
What is capsule endoscopy?
Small camera in tablet swallowed and passes through GI tract and takes pictures
What is the management of acute GI bleeds?
Resuscitate
Clinical assessment – ‘high risk’ or ‘low risk’
Initial investigations – FBC, clotting studies, X-match, EUCs, ECG
Endoscopy
Medical therapy
Surgery when indicated
Describe the process of resuscitation
Airway, aspirate blood from pharynx
IV access: large-bore venflon or central loine
Take blood for cross-match
IV fluids
o If tachycardic or hypotensive, give colloid (fluids) while waiting for blood
o Transfuse to Hb of 10g/dl
o Aim for CVP (central venous pressure) of 5-8cm – JVP
Consider urinary catheter, transfer to ITU - urine output is a good indicator of if the kidneys are being perfused
What factors are good at predicting significant risk of dying from GI bleed
Age >65yrs
Co-morbidity (e.g. IHD, COAD, cirrhosis)
Pulse > 100bpm, BP <100 systolic (or postural drop)
Re-bleed in hospital
Suspected variceal haemorrhage
Shock on admission
Ascites
Continued bleeding
Hb < 8g on admission
What is the Rockall criteria?
Risk assessment for re-bleeding and outcome
Max score=11
As score increases chances of dying increases
What is management or high risk patients
HDU -> endoscopy
What is the management for low risk patients
General ward -> endoscopy
Describe endoscopy
Within 24hrs = consider urgently for high risk patients or suspected varices
Aspirate blood from stomach
Endoscopic intervention
o Ulcers, high risk stigmata = active bleeding, visible vessel in ulcer base, adherent clot
o Varices
Name some endoscopic findings?
Clean base Flat spot NBVV Adherent clot Active bleeding
What is the endoscopic treatment for bleeding ulcers?
Injection – adrenaline, sclerosants, thrombin/fibrin glue
Electrocoagulation
Clips
Heater probe
Argon plasma coagulation (APC)
What is the outcome for endoscopy for
- Active bleeding, visible vessel
- Clot/spot
- Clean base
- HDU 48 hours -> genera ward 1 day
- General ward 2 days
- General ward 1 day
Describe post endoscopy management?
Can eat and drink 4-6 hours after therapeutic procedure
Repeat endoscopy – clinical evidence of active re-bleeding, concerns regarding optimal initial endoscopy management
Repeat endoscopic therapy for re-bleeds
Consider angiographic cessation of bleeding
What is the management for lower GI bleed?
Normal endoscopy
Colonoscopy
o Cause of bleeding o Prognosis
o Endoscopic therapy
Angiography
o MR angiography
o Femoral angiography
o Angiographic intervention
Omeprazole – important pharmacology for GI bleeds
Describe surgery for bleeding ulcers?
Re-bleeding – single re-bleed in high risk patients, two re-bleeds in low risk
Uncontrolled bleeding at endoscopy
Transfusion requirement
o >4 units for low risk
o >8 units for highrisk
What is seen clinically following variceal bleeds
Known cirrhosis
Portal vein thrombosis
Jaundice
Splenomegaly
Ascites
> 1 stigmata of chronic liver disease
Decreased platelets
Increased MCV
Increased INR (International normalised ratio=2-3 on warfarin)
Decreased albumin, urea and Na
What is the management for varices?
Monitor on ITU
o Central line
o Urine output
o Regular FBC, clotting, creatinine, electrolytes, blood gases
Replace clotting factors = FFP, platelets, etc.
Vasopressin, glypressin
Somatostatin, octreotide
Endoscopy
o Sclerotherapy – causes scaring and fibrosis
o Banding – more common, elastic bands on blood vessels to stop them bleeding
