Y3 Lecture week IV > Upper GI bleed > Flashcards

Upper GI bleed Flashcards

(48 cards)

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1
Q

Causes of upper GI bleed (oesophageal)

A

Oesophageal causes of upper GI bleed

  • varies
  • oesophagitis
  • cancer
  • Mallory-Weiss tear
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2
Q

Causes of gastric bleeding

A
  • gastric Ca
  • diffuse erosive gastritis
  • Dieulafoy lesion
  • gastric ulcer
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3
Q

What is the most common cause of major upper GI hemorrhage?

A

Posteriorly sided duodenal ulcer

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4
Q

What should patients with suspected varices receive propr to the endoscopy

A

Terlipressin - it is a vasopressin analogue -> vasoconstriction caused

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5
Q

Management of upper GI bleed

A
  • early control of airway + resuscitation if needed
  • investigate: bloods, upper GI endoscopy within 24 hours
  • further Rx depends on the cause of hemorrhage

-

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6
Q

Treatment of oesophageal varices causing upper GI bleed

A
  • banding
  • sclerotherapy

If these do not work:

Sengaksten- Blakemore tube (or Minnesota tube)

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7
Q

Treatment of patients with erosive oesophagitis / gastritis

A

Erosive oesophagitis/ gastritis Rx

  • proton pump inhibitor
  • identifiable bleeding points -> combination therapy of injection of adrenaline and either a thermal or mechanical treatment.
  • all patients who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.

* Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy

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8
Q

Which vessel is usually involved in the bleeding in duodenal ulcer

A

Gastro-duodenal a.

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9
Q

which vessel is usually involved in the bleeding from the gastric ulcer

A

left gastric artery

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10
Q

What score is used to predict the severity of upper GI bleed? (if admission and endoscopy is needed)

A

Blatchford score

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11
Q

What are the components of Blatchford score assessment?

A

Patient’s: Hb, serum urea, pulse rate and BP

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12
Q

What indicates low and what indicates a high risk on Blatchford score?

A
  • patients with a score of 0 are low risk
  • all others are considered high risk and require admission and endoscopy
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13
Q

What to calculate following the endoscopy? Why?

A

Rockall score - to determine the patient’s risk of rebleeding and mortality

* A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge

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14
Q

Rx for Mallory Weiss tear

A
  • Mallory Weiss tears will typically resolve spontaneously
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15
Q

Surgical treatment for duodenal ulcer

A

Duodenal ulcer - surgery

  • Laparotomy, duodenotomy and under running of the ulcer

*duodenotomy - excision of parts or all of the duodenum

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16
Q

Treatment (surgical) for bleeding gastric ulcer

A
  • Under-running of the bleeding site - suture ligation /podwiazanie/ of the bleeding vessel
  • Partial gastrectomy-antral ulcer
  • Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery)
  • Total gastrectomy if bleeding persists
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17
Q

What does Haematochezia mean?

A

Haematochezia

/hematoczesja/

Passing fresh blood - blood does not have time to be altered

*passed usually PR

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18
Q

What two groups of meds are associated with upper GI bleed

A

Drugs to be asked about while taking a history from a patient with an upper GI bleed

A. Mucosal damage (e.g. NSAIDs)

B. Impaired hemostasis(e.g. Warfarin)

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19
Q

Drugs that may cause mucosal damage (contributing to an upper GI bleed)

A

Mucosal damage:

  • NSAIDs
  • COX 2 inhibitors
  • Prednisolone

*all steroids, all anti-inflammatory (e.g. Naproxen, Ibuprofen, Diclofenac)

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20
Q

Drugs that impair hemostasis (therefore may impact on upper GI bleed)

Study These Flashcards
A

Drugs that impair haemostasis:

  • Warfarin
  • DOACs / NOACs
  • Heparin/LMWH
  • anti-platelets
  • clopidogrel
  • Aspirin
21
Q

What does support the diagnosis of GI bleed? (4)

Study These Flashcards
A
  • Hx of melena
  • Melena on PR
  • ratio of blood urea nitrogen to serum -> urea will go up
  • creatinine greater than 30
22
Q

What is the Rockall score used for?

What is the Blatchford (Glasgow-Blatchford) score used for?

Study These Flashcards
A
  • Rockall score -> to predict mortality
  • Glasgow - Blatchford -> to see who we need to admit
23
Q

What does go up with upper GI bleed?

24
Q

What score on Blatchford scale would indicate the need for admission (and need for upper endoscopy)?

Study These Flashcards
A

Score of 1 or more

(only score of 0 indicated low risk -> so pt can be discharged)

25
What signs are suggestive of upper GI bleed?
* are they hypotensive? (\>15% postural drop) * tachycardia
26
**Classes of an acute haemorrhage** What is important to know?
Important: a patient with a significant bleed (1500 or above) will show signs \*Signs: tachycardia, hypotension, decreased urine output, reduced LOC
27
How much blood is lost in an acute haemorrhage?
**Class I** (\<750) 15% **Class II** (750 - 1500) 15 - 30% **Class III**(1500 - 2000) 30-40% **Class IV** (\>2000) \>40%
28
What do we need to consider in terms of ***hemorrhage*** in a patient who is on ***beta-blocker***?
HR rate may not be up even with a significant bleed
29
The lethal **triad of coagulopathy** - what does it involve?
* hypothermia * acidosis * coagulopathy ## Footnote (lethal triad applies to each acute bleeding)
30
**What Dx would be these elements in Hx indicative of?** - NSAID use, previous ulcer, systemic illness
* peptic ulcer disease * gastroduodenitis
31
**What Dx of upper GI bleed would be these elements in Hx indicative of?** - Alcohol excess, chronic liver disease, spider naevi, jaundice, hepatosplenomegaly, encephalopathy, ascites
Varices/ portal hypertensive gastropathy
32
**What Dx of upper GI bleed would be these elements in Hx indicative of?** - excessive retching and vomiting prior to haematemesis
Mallory-Weiss tear
33
**What Dx of upper GI bleed would be these elements in Hx indicative of?** - weight loss, dysphagia
- stricture - malignancy
34
**What Dx of upper GI bleed would be these elements in Hx indicative of?** - chronic reflux, bisphosphonate use
Oesophagitis
35
**What Dx of upper GI bleed would be these elements in Hx indicative of?** Previous abdominal aortic aneurysm repair
aorto-enteric fistula
36
**What Dx of upper GI bleed would be these elements in Hx indicative of?** Chronic kidney disease
***Vascular ectasia*** - dilated small blood vessels in pyloric antrum -\> bleeding into intestine - it is known as 'watermelon stomach' - due to pattern of bleed and appearance
37
**What Dx of upper GI bleed would be these elements in Hx indicative of?** Recent ERCP
***Post- sphincterotomy*** bleed
38
**What Dx of upper GI bleed would be these elements in Hx indicative of?** Peritonitis
Perforated ulcer
39
**What Dx of upper GI bleed would be these elements in Hx indicative of?** cachexia/lymphadenopathy
malignancy
40
Investigations in pt coming with upper GI bleed
- **FBC** -\> hemoglobin may not be yet decreased in acute bleed - **U+E** -\> to see urea levels (up in the bleed) - **LFTs** -\> due to the impact of chronic liver disease - **glucose** -\> check for hypoglycemia - **G+S +/-** **cross match** - **ECG** -\> to see if bilirubin has an effect on the heart **-** **errect** **CXR** -\> to see for perforation \*G+S if pt reports bleeding but obs stable and appears well \* cross match - if pt is unstable
41
Do we give PPI before the endoscopy?
Not according to NICE guidelines \*may affect the results of biopsy if to be taken during endoscopy
42
Management of upper GI bleed (in general) - meds wise - non-meds wise
_Meds:_ - IV ***Metoclopramide*** (anti-emetic) - IV n***Terlipressin*** (if Hx suggestive of varices - to vasoconstrict) - blood transfussion -\> if indicated - IV ***vitamin K/FFP/ platelets*** -\> if indecated _Other:_ - endoscopic options
43
Surgical options of management of upper GI bleed
Options depend on the source/cause of bleeding: - embolization (cut off blood supply to the bleeding) - TIPS - transplantation
44
Risk factors for bleeding of the varices
- variceal size -\> the bigger they are - the more chances of bleed - the presence of endoscopic red color signs (e.g. cherry red spots, red markings) - active alcohol use - Child classification -\> to classify severity of liver disease -\> more severe = more likely to bleed
45
What scale is used to classify the severity of liver disease?
The ***Child - Pugh*** classification
46
Why do we give antibiotic for a patient with upper GI bleed?
When a patient is encephalopathic -\> change of the gut bacteria (translocation) -\> release of endotoxin into systemic circulation -\> sepsis and hemodynamically unstable
47
Thresholds and Mx for coagulopathy: - platelets - INR - aPTTr - Fibrinogen
48
What to advice on the discharge of pt after upper GI bleed (if the cause was ulcer)
* H-pylori treatment (if present) * Ulcers: PPI for an initial period of 6-8 weeks * Ulcers: stop NSAIDs/ Cox 2 inhibitor * Perhaps clopidogrel * if pt needs to take anti-inflammatory -\> consider COX 2 inhibitor * if aspirin is needed -\> prescribe PPI with it * repeat endoscopy in 6-8 weeks -\> to ensure the healing and exclude malignancy
Y3 Lecture week IV
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