GI bleed

Question 1

Etiology of upper GIT bleed

Answer 1

1. PUD
2. Esophageal varices
3. Esophagitis
4. Mallory weiss tear

Question 2

Rockall scoring system

Answer 2

Age
Shocked
Co-morbidities
Endoscopic findings/diagnosis
Bleeding visible

Question 3

History for UGIB

Answer 3

1. Onset, amount
2. NV-> (N: distal bleed to pylorus), coffee ground emesis (PUD, variceal less likely)
3. After vomiting->tear
4. Melena
5. Hematochezia->more lower
6. Diet
7. Constitutional
8. Medications->NSAIDs, anticoagulants
9. ALcohol, chronic liver disease
10. Other medical history
11. Social, origin

Question 4

Examination in UGIB

Answer 4

1. Vitals->degree of anemia/hypovolemia
2. Signs of chronic liver disease
3. Abdominal tenderness
4. DRE
5. Cachexia
6. Hoarseness

Question 5

Investigations in UGIB

Answer 5

FBC
Coagulation
Group and hold
LFTs
UEC

May consider abdominal CT if cause of bleeding not clear

Question 6

Management of UGIB (if shocked)

Answer 6

1. ABC, NBM
2. 2 large IV cannula, urinary catheter
3. Bloods for FBC, UEC, coags, GH, glucose LFTs
4. Cross match
5. High flow oxygen
6. Rapid IV infusion
7. If remains shocked->pRBC infusion
8. FFP is coagulopathy
9. Monitor urine output >30ml/h
10. Monitor vitals / 15 mins until stable, then hourly
11. Notify surgeons
12. Admits
13. Endoscopy for diagnosis/control of bleeding (needs to be hemodynamically stable)
14. Following endoscopy->omeprazole

In variceal bleeds

1. Giver terlipressin IV, or octreotide
2. Transjugular intrahepatic portosystemic shunt
3. Sengstaken-Blakemore or Linton-Nachlas

Question 7

Etiology of LGIB

Answer 7

1. Diverticular disease
2. Colonic angiodysplasia
3. Ischemic colitis
4. Crohns, UC
5. Infectious colitis
6. CRC
7. Internal hemorrhoids
8. Anal fissure
9. Colonic polyps

Question 8

Examination in LGIB

Answer 8

1. Vitals signs
2. Abdomen
3. Rectal

Question 9

Investigations in LGIB

Answer 9

1. FBC
2. Coags
3. GH,, Xmatch
4. ESR
5. Stool MCS
6. Anoscopy
7. Colonoscopy, OGD
8. Angiography if persistent and negative colonoscopy
9. CT abdomen->ischemic colitis, aorto-enteric fistula
10. ANA, ANCA if suspect vasculitis

Question 10

Management of LGIB

Answer 10

1. Start with ABC.
2. Ensure that at least one large peripheral cannula is in place. Take blood for FBC, UþEs, group and save.
3. Check pulse and blood pressure; give fast IV colloid if
   pulse > 100 or systolic BP 4. Take a history: fresh blood suggests a rectal or perianal bleed and is more common in younger patients. Partially altered blood and clots suggest colonic bleeding and tend to be found in older patients. Is there a history of anaemia?
4. Ask about weight loss and a history of a change in bowel habit.
5. Take a full drug history: is the patient on warfarin or NSAIDs? Ask about alcohol use.
6. Check vital signs and look for signs of weight loss or bleeding elsewhere.
7. Examine the abdomen for masses or enlarged liver or spleen. Perform a rectal examination and examine the perianal area for evidence of fresh blood.
8. If the patient has fresh blood present, organize a flexible sigmoidoscopy once the bleeding has settled.
9. If the patient has altered blood PR, organize either a colonoscopy once the bleeding has settled.
10. Conservative management should be pursued if possible.
11. If the patient is shocked, resuscitate with IV colloid through two large-bore cannulae and call for
    senior help.
12. Group and save and transfuse if Hb If the patient is stable: give fluids – IV normal saline over 4–6 h.
13. If the patient is anaemic and requires transfusion, give blood as necessary to raise the haemoglobin to 10 g/dL.