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

• 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