GI Haemorrhage

Question 1

describe melaena

Answer 1

black, thick, sticky, semi liquid stool

Question 2

what is vomiting blood called

Answer 2

haematemesis

Question 3

what are the most common causes for a GI bleed

Answer 3

duodenal ulcer, gastric erosions, gastric ulcer, varices

Question 4

what is a mallory-weiss tear

Answer 4

distal oesophageal tear due to repeated vomiting

Question 5

what is the immediate treatment for a GI haemorrhage

Answer 5

resuscitation, ABC: airway protection, oxygen, IV access, fluids

Question 6

why must a grey IV access cannula be used

Answer 6

as it is the largest bore, 2 can maintain pace of GI bleed

Question 7

what is the 100 rule

Answer 7

used to assess the severity- people in a poor prognostic group
systolic BP < 100mmHg
pulse > 100 bpm
Hb < 100
age > 60
comorbid disease 
postural hypotension

Question 8

what else might affect people ability to compensate for a GI bleed

Answer 8

diabetes- poor autonomic response

beta blockers

young people compensate well but crash hard if below 1.5 litres of blood (average in adult is 5 litres circulating)

Question 9

what is an OGD

Answer 9

oesophageal gasto duodenoscopy

Question 10

what is the uses of the OGD

Answer 10

identify cause, therapeutic manoeuvres, asses risk of rebleeding

Question 11

what co morbiditys increase the rockall risk scoring system

Answer 11

2:
IHD, CCF,
3:
renal or liver failure, malignancy

Question 12

what are features of a high risk ulcers/ the stigmata of recent haemorrhage

Answer 12

active bleeding/oozing, overlying clot, visible vessel

Question 13

what does the blatchford score assess

Answer 13

risk of GI bleed- a score of 0-1 means patient can be discharged with arrangement for later endoscopy

Question 14

what are the treatments for a bleeding peptic ulcer

Answer 14

endoscopic treatment (high risk ulcers)
acid suppression (infusions omeprazole) 
intervention radiology 
surgery
H. pylori eradication (secondary prevention)

Question 15

what is involved in the endoscopic treatment of peptis ulcers

Answer 15

injection 
heater probe coagulation 
combinations
clips 
haemospray

Question 16

how does an endoscopic injection work to stop a peptic ulcer bleeding

Answer 16

as injection of adrenaline shifts the thrombotic- fibrinolytic (acid and pepsin in lumen) balance towards clot formation (fibrinolysins in blood vessel)

Question 17

what is endoscopic dual therapy

Answer 17

injection + heater probe/ clip

Question 18

how dilated is the adrenaline in an endoscopic injection

Answer 18

1:10000

Question 19

where are the endoscopic clips placed

Answer 19

on vessels one either side of ulcer

Question 20

what is hemospray

Answer 20

When Hemospray comes in contact with blood, the powder absorbs water, then acts both cohesively and adhesively, forming a mechanical barrier over the bleeding site.

Question 21

what is the purpose of acid suppression and what is used to do this

Answer 21

prevents re bleeding- IV omeprazole

Question 22

what is the treatment pathway of a successfully treated peptic ulcer

Answer 22

PEPTIC ULCER AT ENDOSCOPY
(bleeding or with stigmata of recent haemorrhage)

adrenaline injection/heater probe thermo-coagulation/clips

bleed stops

omeprazole 80mg iv
+
8mg/hr/72hrs ivi

H. pylori eradication
as appropriate and
course of oral PPI

Question 23

what should yuo do if there is a re-bleld of a peptic ulcer after dual therapy

Answer 23

omeprazole 80mg iv
+
8mg/hr/72hrs ivi

Further attempt at
endoscopic therapy

(if bleed continues)

surgery

Question 24

what is a ppi and give exmaple

Answer 24

proton pump inhibitor, acid suppressor, omeprazole

Question 25

what is the main cause of variceal bleeds

Answer 25

liver disease- cirrhosis- portal hypertension

Question 26

what is the main complication of liver diease

Answer 26

sepsis

Question 27

what is childs score

Answer 27

measure of severity of liver disease, A, B, C- C most severe

Question 28

what are the risk factors for a variceal bleed

Answer 28

- portal pressure > 12mmHg - varices > 25% oesophageal lumen - presence of red signs (mucosal weakening) - degree of liver failure (Child’s A

Question 29

why is the mortality of variceal bleeds so high (25-50%)

Answer 29

due to complications - sepsis, liver failure

Question 30

what is the anatomy of varises

Answer 30

As cirrhosis advanced resistance to portal vein increases which increases portal pressure Blood tries to find other way back than through the liver- drain upwards through the parioesophageal venous plexus to try and get back to azygous vein, vessels distend and causes oeshophageal varisces

Question 31

what would make you suspect varices in a patient with a GI bleed

Answer 31

``` known history of cirrhosis with varices history; -chronic alcohol excess -chronic viral hepatitis infection -metabolic/ autoimmune liver disease -intra-abdominal sepsis/surgery ``` on examination: -stigmata of chronic liver disease

Question 32

what are the stigmata of chronic liver disease

Answer 32

spider naevi, palmar erythema, encephalopathy (nuerotoxic effect on the brain, liver flap, drowsy, inability to copy 5 sided star), ascites, jaundice, leukonychia

Question 33

what are the aims of management of a variceal GI bleed

Answer 33

``` Resusciation Haemostasis Prevent complications of bleeding Prevent deterioration of liver function Prevent early re-bleeding ```

Question 34

what ions might need to be replaced in a GI bleed

Answer 34

K+, MG2+ and (PO4)2-

Question 35

how is haemostasis

Answer 35

Terlipressin (vasopressin analogue- constricts blood supply to the gut so reduces portal pressure) Endoscopic variceal ligation (banding) (Sclerotherapy) Sengstaken-Blakemore balloon TIPS- decompresses portal venous system

Question 36

what is terlipressin

Answer 36

vasopressin pro drug- splanchnic vasoconstrictors, beneficial effect of renal perfusion

Question 37

when should a sengstaken- blakemore tube be used

Answer 37

as a delay until endoscope

Question 38

what is TIPS

Answer 38

blood shortcuts liver and goes straight to systemic venous system reducing portal pressure

Question 39

why is propanolol used in a variceal bleed

Answer 39

to reduce portal blood pressure

Question 40

why is banding used in variceal bleeds

Answer 40

is a further procedure to completely get rid of varices