GI Bleeds and The Acute Abdomen

Dr James Byrne FY1 - Gastroenterology

Contents
Upper GI bleeds Lower GI bleeds The Acute abdomen The role of the F1

Upper GI Bleeds
Most common causes
Mallory-weiss tear 10% Duodenal/gastric ulcers 50% (30%/20%) Oesophageal varices 5% Oesophagitis/gastritis 25% Upper GI malignancies 3%

Common symptoms
Frank blood: Oesophogeal varices can cause exsanguination Coffee ground vomit Malaena Anaemia Abdominal pain

Case 1
A 22yr old male presents to A+E with haematemesis. He was out with friends the previous night and had a few too many. He has had several episodes of vomiting today, the last of which contained a moderate volume of fresh red blood. Obs: BP 125/80, HR 66, RR 16, Sats 99% Bloods: Hb 142 Plt 250 Ur 4.5

Are you worried? Initial management Provisional diagnosis?

Mallory weiss tear

Oesophageal tear most commonly caused by repeated vomiting. Usually acute and self limiting. Requires no intervention.

Case 2
52 year old female alcoholic presents to SAU after vomiting fresh red blood at home. She has never had this before. Reports black smelly stools yesterday. Abdominal examination reveals ascites and caput medusa. During your consultation she has a large volume haematemesis.

Obs: BP-95/60 HR-100 RR-20 Bloods: Hb 78 Ur 12

Are you worried? Initial management/investigations? Differential diagnosis

Oesophageal Varices
Aetiology: Portal hypertension causes the formation of collateral veins at the gastrooesophageal junction. These veins can be prone to rupture due to their superficial nature. Management:
Initial resuscitation Urgent endoscopy needs to be performed to rule out other causes and to confirm varices. Bleeding varices can be banded or sclerosed during OGD

Duodenal/Gastric Ulcers
95% of Peptic ulcer disease is associated with H.Pylori Duodenal 4x more common than gastric 80% associated with H Pylori, increased risk with smoking, NSAIDS and stress At risk of bleeding and/or perforation

Common Principles
GI bleeds are an emergency. They require senior assistance. As the F1 you need to initiate appropriate investigations and management:
Blood tests FBC, U+E, amylase, clotting, G+S and cross match AXR and erect CXR Appropriate analgesia Haemodynamically stable? IVI? Transfusion?

Bonus points
Score 0 Variable Rockall score:
[2]

Score 1 60- 79 Pulse >100 BP >100 Systolic >80

Score 2

Score 3

Age

<60

Glasgow-Blatchford score
Shock No shock
Co-morbidity Nil major All other diagnoses

SBP <100
Renal failure, CHF, IHD, major liver failure, morbidity metastatic cancer GI malignancy Blood, adherent clot, spurting vessel

Diagnosis Evidence of bleeding

Mallory-Weiss

None

 Rockall score: assesses the risk of adverse outcome following a major bleed. A score of <3 indicates a 0% martality rate, whereas a score of >7 indicates a 50% mortality rate. Glasgow Blatchford score: assesses the risk that a patient will have to have interventional treatment such as transfusion/endoscopy.

Lower GI Bleeds
Upper GI bleeds pose a much more serious risk of marbidity and mortality. Lower GI bleeds tend to be more superficial;
Anal fissures Haemorrhoids IBD Diverticulosis Colorectal carcinoma

The Acute Abdomen

Acute pain and illness associated predominantly with the abdomen is referred to as an Acute Abdomen. There are numerous causes, some of which may require emergency intervention. As the surgical F1, you are likely to be the first person to fully clerk and examine the pt.

Causes

Appendicitis
Umbilical pain, migrates to the RIF Assoc with guarding and peritonism Decreased appetite This is most commonly a clinical diagnosis. Patients should be referred to a senior. CT scan is the only definitive imaging. McBurneys point and Rovsings sign

Perforated peptic ulcers

Intense upper abdominal pain associated with peritonism. Signs: shock, prostration, lying still, abdominal rigidity and guarding

CXR

Bowel Obstruction
Vomiting, reduced/absent BO Absent flatus Colicky abdominal pain

Differences between small and large bowel?

Imaging? Treatment?

AXR

Gall stones
Cholangitis, cholelithiasis, cholecystitis Normally presents with RUQ pain, waxing and waining in nature rather than colicky. Diagnosed via USS MRCP vs ERCP? Cholecystectomy?

Pancreatitis
Characterised by severe epigastric pain radiating to the back, relieved by sitting forwards Increased amylase is diagnostic but not always present Glasgow score:
PaO2, Age, Neutrophilia, Calcium, Renal function (urea), Enzymes, Albumin, Sugar. A score of >3 necessitates discussion with HDU

Management:
NBM +/- NG tube Appropriate analgesia Antibiotics?

The role of the F1

You will see all of the above during your first week as a surgical F1 DONT PANIC! Every patient will require the following:
History and examination even if only brief NBM Full bloods, CRP, Amylase + G+S/Xmatch Appropriate imaging ordered (A/CXR, USS, CT/MRI) IVI and analgesia Extras: eg NG tube (ryles)/catheter

Questions?

Good luck!!