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Chapter: Medicine Study Notes : Gastro-Intestinal

GI Bleeding

Haematemesis (either fresh or coffee ground appearance): check not coughing it up. Can check vomit with urine dipstick for blood

GI Bleeding


Upper GI Haemorrhage


·        Symptoms/Signs:


o   Haematemesis (either fresh or coffee ground appearance): check not coughing it up. Can check vomit with urine dipstick for blood


o   Melaena (black/sticky foul smelling stools): stomach denatures haemoglobin ® black. So no melaena if bleed beyond proximal small bowel. Exclude iron tablets, bismuth preparations & Guinness


o   Rectal bleeding (haematochezia)

o   Anaemia: tired, pale, breathless, faint (brain struggles to compensate if PO2 <60 mmHg)


o   Hypovoleamia: carotid bodies ® sympathetic ® ↑HR & peripheral vasoconstriction; ↓renal perfusion ® ↑renin ® ↑angiotensin (vasoconstriction) ® ↑aldosterone (H2O retention); ↑ADH ® thirst and H2O retention. If serious hypovoleamia: postural hypotension, cold & clammy, confused, thirsty, weak pulse & tachycardic, ↓urine output


o   Check stridor: tumour compressing trachea – expiratory wheeze

·        History:

o   Always ask about CV and respiratory history, and when they last ate, in case surgery is needed

o   Medications: NSAIDs (if so, then steroids further increase risk), anticoagulants

·        Investigations:


o   Bloods: anaemia, reticulocytes, group & hold, U &Es, Liver fn (is it varicies?), clotting (either poor liver function or Warfarin ® bleeding)

o   Endoscopy (can do biopsy)

o   Barium swallow (not so good)


·        Causes: Tear, varices (check splenomegaly, spider naevi, palmar erythema, risk of death 30%, risk of rebleed, 30%), oesophagitis (e.g. from reflux or ulcer), Mallory-Weiss tear from repeated vomiting, gastritis (e.g. alcoholic), ulcer, malignancy (check for masses, lymph gland enlargement, organomegaly), ulcer (NSAIDs)


·        Causes of small bowel bleeding (eg if no upper or lower cause found):

o   Under 25: Meckel‟s diverticulum

o   30 – 50: Small bowel tumour

o   Over 50: angiodysplasia


 Lower GI Haemorrhage


·        Symptoms/Signs:


o   Blood in/with stool. Colour indicates site: if bright red Þ 95% of pathology distal to splenic flexure (usually anus & rectum) 

o   Pain on passing motions Þ anal fissure (haemorrhoids don‟t cause pain unless prolapsed)

o   Anaemia 

o   Angina (in elderly with CHF, anaemia ® angina due to ↓O2 ® ↑heart work)

o   Check: Meikels diverticulum – lined with gastric mucosa

·        Family Hx: colorectal cancer/inflammatory bowel disease

·        Rectal Exam (Always do abdominal exam as well)


o   Look first: skin tags Þ Crohn‟s, sentinel tags Þ chronic anal fissure

o   Digital examination: if acute fissure this will be very painful (Þ give up)

o   Rigid sigmoidoscope: in 2/3 can only see rectum


·        Investigations: rectal exam, sigmoidoscopy, colonoscopy, barium enema, bloods (anaemia, reticulocytes)

·        Causes:

o   Diverticular disease (brisk bleeding with sudden onset)

o   Inflammation (ulcerative colitis, etc)

o   Infection (e.g. campylobacter)

o   Colorectal cancer

o   Angiodysplasia

o   Haemorrhoids (blood coats bowel motion with drops after motion passed)

o   Anal Fissure (pain passing motion)

o   Anal Cancer

o   Upper GI bleeding (check with an NG aspirate)

 Treatment of Major GI Haemorrhage


·        Resuscitate:


o  Colloid drip (expand vascular volume – not crystalloid – that shifts into interstitial space, 14 or 16 gauge) 

o  If meet any of the criteria for shock then transfer to ICU: postural hypotension > 15 mmHg fall, tachycardia > 100, systolic BP < 100.

o  Check thirst/urine output (insert catheter)

o  Max O2


·        Bloods: group and hold (don‟t match until sure you need it), ABG, Hb, baseline creatinine before renal failure, ↑urea – may be due to breakdown of blood in gut, check platelets, INR & APTT for liver disease, bleeding disorders, warfarin OD)


·        Find cause:


o  ANY melaena ® upper GI down to proximal small bowel

o  Endoscope for upper:


§  Don‟t endoscope until resuscitated – but do it early. If they rebleed and surgery is required, the surgeon will want to know where its from


§  Endoscope for varices ® injection sclerotherapy (e.g. ethanolamine oleate), balloon tamponade


o  For lower bleeding:

§  Sigmoidoscope: check no mass

§  Colonoscopy 

§  If pain ® ischaemic colitis

§  If aortic surgery ® aorticduodenal fistula 

§  If not stopping, either labelled red cell scan (view with gamma camera) or mesenteric angiogram (contrast via femoral artery into mesenteric arteries) to guide surgery. These only detect active bleeding


·        65% will spontaneously stop ® resuscitate/transfuse and investigate less urgently

·        Indications for surgery:

o  Failure of conservative treatment

o  In shock, rebleed, etc

o  Consider if > 6 units of blood needed over 24 – 48 hours


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