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Flashcards in GI Drug Loss Deck (25)
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1
Q

What is the

  1. Incidence
  2. Mortality
  3. Chance of re-bleed

For acute GI bleeds

A
  1. 100 per 100,000 population each year
  2. 14% (in specialised bleeding unit=5%
  3. 20%
2
Q

What are the sites of GI bleed?

A

Upper GI bleed (70%) – oesophagus, stomach, duodenum Small bowel GI bleed (rare <1%)
Large bowel GI bleed (common 30%)

3
Q

What is the clinical presentation of acute GI bleed?

A

Haematemesis – throwing up blood
Melena – digested blood in stools
Shock
Per rectum (Pr) bleed – fresh blood in stools

4
Q

What is the clinical presentation of chronic GI bleeds?

A

Anaemia, iron-deficient (microcytic)
Positive faecal occult blood (FOB) test – picked up in bowel cancer screening test, detects
presence of blood in stools

5
Q

What are the causes of upper GI bleeding?

A

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%)

6
Q

What are the causes of GI bleed in the small bowl?

A

Jejunal/ileal diverticula

7
Q

What are the causes of GI bleed in the large bowel?

A

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

8
Q

What is the management of chronic GI bleeds?

A

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

9
Q

What is capsule endoscopy?

A

Small camera in tablet swallowed and passes through GI tract and takes pictures

10
Q

What is the management of acute GI bleeds?

A

Resuscitate

Clinical assessment – ‘high risk’ or ‘low risk’

Initial investigations – FBC, clotting studies, X-match, EUCs, ECG

Endoscopy

Medical therapy

Surgery when indicated

11
Q

Describe the process of resuscitation

A

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

12
Q

What factors are good at predicting significant risk of dying from GI bleed

A

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

13
Q

What is the Rockall criteria?

A

Risk assessment for re-bleeding and outcome

Max score=11

As score increases chances of dying increases

14
Q

What is management or high risk patients

A

HDU -> endoscopy

15
Q

What is the management for low risk patients

A

General ward -> endoscopy

16
Q

Describe endoscopy

A

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

17
Q

Name some endoscopic findings?

A
Clean base
Flat spot
NBVV
Adherent clot 
Active bleeding
18
Q

What is the endoscopic treatment for bleeding ulcers?

A

Injection – adrenaline, sclerosants, thrombin/fibrin glue

Electrocoagulation

Clips

Heater probe

Argon plasma coagulation (APC)

19
Q

What is the outcome for endoscopy for

  1. Active bleeding, visible vessel
  2. Clot/spot
  3. Clean base
A
  1. HDU 48 hours -> genera ward 1 day
  2. General ward 2 days
  3. General ward 1 day
20
Q

Describe post endoscopy management?

A

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

21
Q

What is the management for lower GI bleed?

A

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

22
Q

Describe surgery for bleeding ulcers?

A

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

23
Q

What is seen clinically following variceal bleeds

A

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

24
Q

What is the management for varices?

A

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

25
Q

What are he complications of sclerotherapy?

A

Bleeding

Ulceration, perforation, stricture

Embolization of sclerosant

If uncontrolled consider Sengstaken tube