Locations
- Haematemesis
- Start: Nose/Mouth
- Finish: Ligament of Treitz (D3)
- Melena
- Start: Nose/Mouth
- Finish: Iliocaecal valve
- Takes about 14 hours for blood to be broken down within the intestinal lumen
- If transit time is less than 14 hours the patient will have hematochezia
- If greater than 14 hours the patient will exhibit melena
Ligament of Treitz - Connects the duodenum to the diaphragm
- Inserts into the third and fourth portions of the duodenum and frequently into the duodenojejunal (DJ) flexure
- When it contracts, the suspensory muscle of the duodenum widens the angle of the duodenojejunal flexure, allowing movement of the intestinal contents
Melena - Sinister symptom
- Syncope/pre-syncope
- e.g. Went to the toilet, Saw blood, Stood up, Fainted
Relevant drugs - NSAIDS, aspirin, warfarin
- Beta blockers - Mask reflex tachycardia
Bad prognostic features - Heart failure
- Ischaemic heart disease
- Renal failure
- Liver failure
- Metastatic cancer
Perforated DU - Used to do excision and end-to-end anastomosis (Billroth procedure)
- Vulnerable to cancer and re-bleeding
- Now overlay layers => Better
Aorto-gastric fistula - From inflamed aorta
- e.g. Rejection of AAA stent
- May mimic ulcer presentation
- But endoscopy negative and omeprazole doesn't help
- Then bleed catastrophically
Stigmata of chronic liver disease - Spider naevi
- Gynaecomastia
- Liver can't metabolise oestrogen
- Loss of secondary sexual hair
- Ascites
- Caput medusae
- Everted umbilicus
- Jaundice
Liver and inflammation - Liver failure => Loss of inflammatory response
- Serious risk of asymptomatic spontaneous bacterial peritonitis
- Must check with an ascitic tap
Rockall score - A - Age
- B - Blood pressure fall (shock)
- C - Co-morbidity
- D - Diagnosis
- E - Evidence of bleeding
| Variable | Score 0 | Score 1 | Score 2 | Score 3 |
|---|
| Age | <60 | 60- 79 | >80 | | | Shock | No shock | Pulse >100
BP >100 Systolic | SBP <100 | | | Co-morbidity | Nil major | | CHF, IHD, major morbidity | Renal failure, liver failure, metastatic cancer | | Diagnosis | Mallory-Weiss | All other diagnoses | GI malignancy | | | Evidence of bleeding | None | | Blood, adherent clot, spurting vessel |
- Interpretation - Mortality
- 1 - Nil
- 2 - Nil
- 3 - 5%
- 4 - 5-10%
- 5 - 5-10%
- 6 - 5-10%
- 7+ - 10-35%
- Most elderly patients are 25-50% mortality risk from a GI bleed!
Things distinguishing an enlarged kidney from an enlarged spleen on examination - The spleen has no palpable upper border
- The space between the spleen and the costal margin (which is present in enlarged kidneys) cannot be felt
- The spleen has a notch that may be palpable
- Spleen moves inferomedially on inspiration while the kidneys move more inferiorly
- Spleen not balottable unless gross ascites present, but kidneys are because of retroperitoneal position
- Percussion note is dull over the spleen but usually resonant over kidneys due to overlying bowel
- A friction rub may be heard over spleen but not over kidney as it is too posterior
Management of GI bleed - Fluids while you're waiting, but they really need BLOOD
- Cryoprecipitate
- Expensive but great at replacing clotting factors
- Vit K, platelets
- Sengstaken-Blakemore tube for varices
- Balloon tamponade
- Just inflate the gastric (not the oesophageal) balloon, to avoid necrosis
- Terlipressin
- Splanchnic vasoconstrictor
- Reduces HPV blood flow => Less bleeding from varices
- Beware gut ischaemia!
- SIRS
- Systemic inflammatory response syndrome
- => BP rise in response to infection
- Can cause varices to pop
- => Manage varices with antibiotics to treat the underlying cause
- Lactulose
- Used to drop gut pH
- Kills bacteria to prevent ammonia production
- May not be converted to urea if your liver's broken
- => Encephalopathy
- Better than using antibiotics (c.f. C. diff)
Notes - Failed discharge is readmission within 48 hrs
- Clot the size of a fist = 500 ml of blood
- Courvoisier's law
- Because the gall bladder with stones is usually chronically fibrosed and therefore incapable of enlargement
- MGMT of Mallory-Weiss tear
- Observe o/n then home
- So don't misdiagnose as e.g. a bleeding ulcer, which means 5 days in hospital!
- Peptic ulcers
- Oesophageal
- Gastric (=> Cancer)
- Duodenal
- Be careful coffee-ground vomiting really is!
- Not just something brown they've eaten
- Melena and haematemesis are both equally life-threatening
- Stomach pH is lowest around the pylorus
- Shutdown? => Femoral
- Don't try to put a central line in the internal jugular as you'll cause a pneumothorax
- Raised urea:creatinine after a bleed (high-protein meal)
- Lots of antibiotics interfere with warfarin metabolism and raise INR!
- The most common GI bleed on the ward is ULCERS
- NICE do not support the use of PPIs pre-endoscopy
- But it can take days to get one done so give them anyway
- High INR alone doesn't cause a bleed
- TIPS
- Transjugular intrahepatic portosystemic shunt
- Establishes communication between the inflow portal vein and the outflow hepatic vein
- Used to treat portal hypertension
- Hb takes a while to fall following a GI bleed
- So check again in 4 hours
- URINE OUTPUT as a marker of volume status
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