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12.11.27 GI bleeds

Locations
  • Haematemesis
    • Start: Nose/Mouth
      • cf Nosebleed
    • 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
    • Fill from the centre
  • 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
VariableScore 0Score 1Score 2Score 3
Age<6060- 79>80
ShockNo shockPulse >100
BP >100 Systolic
SBP <100
Co-morbidityNil majorCHF, IHD, major morbidityRenal failure, liver failure, metastatic cancer
DiagnosisMallory-WeissAll other diagnosesGI malignancy
Evidence of bleedingNoneBlood, 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
    • Investigate the CAUSE
  • 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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