GI Drug Loss

Question 1

What is the

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

For acute GI bleeds

Answer 1

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

Question 2

What are the sites of GI bleed?

Answer 2

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

Question 3

What is the clinical presentation of acute GI bleed?

Answer 3

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

Question 4

What is the clinical presentation of chronic GI bleeds?

Answer 4

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

Question 5

What are the causes of upper GI bleeding?

Answer 5

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%)

Question 6

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

Answer 6

Jejunal/ileal diverticula

Question 7

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

Answer 7

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

Question 8

What is the management of chronic GI bleeds?

Answer 8

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

Question 9

What is capsule endoscopy?

Answer 9

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

Question 10

What is the management of acute GI bleeds?

Answer 10

Resuscitate

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

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

Endoscopy

Medical therapy

Surgery when indicated

Question 11

Describe the process of resuscitation

Answer 11

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

Question 12

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

Answer 12

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

Question 13

What is the Rockall criteria?

Answer 13

Risk assessment for re-bleeding and outcome

Max score=11

As score increases chances of dying increases

Question 14

What is management or high risk patients

Answer 14

HDU -> endoscopy

Question 15

What is the management for low risk patients

Answer 15

General ward -> endoscopy

Question 16

Describe endoscopy

Answer 16

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

Question 17

Name some endoscopic findings?

Answer 17

Clean base
Flat spot
NBVV
Adherent clot 
Active bleeding

Question 18

What is the endoscopic treatment for bleeding ulcers?

Answer 18

Injection – adrenaline, sclerosants, thrombin/fibrin glue

Electrocoagulation

Clips

Heater probe

Argon plasma coagulation (APC)

Question 19

What is the outcome for endoscopy for

1. Active bleeding, visible vessel
2. Clot/spot
3. Clean base

Answer 19

1. HDU 48 hours -> genera ward 1 day
2. General ward 2 days
3. General ward 1 day

Question 20

Describe post endoscopy management?

Answer 20

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

Question 21

What is the management for lower GI bleed?

Answer 21

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

Question 22

Describe surgery for bleeding ulcers?

Answer 22

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

Question 23

What is seen clinically following variceal bleeds

Answer 23

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

Question 24

What is the management for varices?

Answer 24

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

Question 25

What are he complications of sclerotherapy?

Answer 25

Bleeding

Ulceration, perforation, stricture

Embolization of sclerosant

If uncontrolled consider Sengstaken tube