← All decks
General Surgery
Gastrointestinal Bleeding
Built from Maingot's Abdominal Operations
What’s inside
11 sections · 176 slides
Overview
- Scope of this topic
How gastrointestinal bleeding is classified
Upper, lower, obscure and occult - and how common each is
- Upper versus lower gastrointestinal bleeding
- Anatomical division of gastrointestinal bleeding
- Obscure and occult bleeding
- Age, geography and mortality
- Cost of gastrointestinal bleeding
First contact: assessment and resuscitation
Keeping the patient alive comes before finding the cause
- Overall approach to a patient bleeding from the gut
- Sequence of the initial approach
- Priorities in the first minutes
- Bedside signs at each level of blood loss
- Signs that mislead
- Levels of shock by blood loss
- Reading the shock classes
- Fluid resuscitation and monitoring
- Oxygen and the first blood tests
- Transfusion decisions
- Risk scores and predictors of poor outcome
- Limits of the scoring systems
History and examination
What the pattern of bleeding and the patient's story already tell you
- What to ask about the bleeding itself
- Haematemesis
- Melena
- Haematochezia
- Bleeding that presents as anaemia
- Clues in the rest of the history
- Likely causes by age group
- Drug history
- Physical examination
Finding the source of bleeding
Nasogastric aspirate, endoscopy, enteroscopy, angiography and isotope scans
- The nasogastric aspirate
- Upper endoscopy as the gold standard
- Timing of upper endoscopy
- Risks of emergency endoscopy
- Colonoscopy in lower gastrointestinal bleeding
- Why the small bowel is hard to reach
- Capsule enteroscopy
- Deep enteroscopy
- Visceral angiography
- Labelled red cell scanning
Tools for stopping the bleeding
Drugs, endoscopic haemostasis, embolisation and surgery
- Role of drug treatment
- Endoscopic methods of stopping bleeding
- Embolisation through a catheter
- When embolisation fails, and vasoconstrictor infusion
- Place of surgery in gastrointestinal bleeding
Upper gastrointestinal haemorrhage
Non-variceal causes, from peptic ulcer to aortoenteric fistula
- Dividing up upper gastrointestinal bleeding
- Causes of upper gastrointestinal bleeding and their frequency
- Reading the frequency table
- Peptic ulcer disease over time
- 40%
- Who bleeds from a peptic ulcer
- Management algorithm for bleeding peptic ulcer
- Criteria in the Blatchford and Rockall scores
- Rockall and Blatchford scores
- Forrest classification of endoscopic findings
- Using the Forrest grades
- Stopping the drugs that caused the ulcer
- Eradicating Helicobacter pylori
- How gastric acid worsens ulcer bleeding
- Why proton pump inhibitors help
- Endoscopic treatment of a bleeding ulcer
- Metallic clips on a bleeding duodenal ulcer
- Failure of endoscopic therapy and second-look endoscopy
- When peptic ulcer bleeding needs an operation
- Indications for surgery in peptic ulcer bleeding
- Reading the indications for surgery
- Operating on a bleeding duodenal ulcer
- Suture control of a bleeding duodenal ulcer
- Controlling a posterior duodenal ulcer
- Acid-reducing procedures in duodenal ulcer surgery
- Operating on a bleeding gastric ulcer
- Mechanism of a Mallory-Weiss tear
- Where a Mallory-Weiss tear sits
- Presentation and treatment of a Mallory-Weiss tear
- Stress-related mucosal bleeding
- Preventing and treating stress-related bleeding
- Oesophagitis as a source of bleeding
- Reflux oesophagitis at endoscopy
- Infective oesophagitis and treatment
- Dieulafoy's lesion
- Gastric antral vascular ectasia
- Watermelon stomach in the gastric antrum
- Upper gastrointestinal malignancy
- Gastric stromal tumour at endoscopy
- Aortoenteric fistula
- Aortoenteric fistula seen at operation
- Sentinel bleeds and early diagnosis
- Fistulous track into the aneurysm sac
- Imaging and repair of aortoenteric fistula
- Haemobilia
- Haemosuccus pancreaticus
- Bleeding caused by procedures
Variceal bleeding and portal hypertension
Why cirrhosis fills veins that were never meant to carry that much blood
- From cirrhosis to a bleeding varix
- Varices and portal hypertension
- What makes a varix bleed
- Isolated gastric varices
- Portal hypertensive gastropathy
- Snake-skin pattern of portal hypertensive gastropathy
- Management algorithm for variceal bleeding
- Diagnosing a variceal bleed
- Drug treatment of variceal bleeding
- Band ligation of varices
- Balloon tamponade
- Managing gastric varices
- Preventing a second variceal bleed
- Transjugular intrahepatic portosystemic shunt
- Surgical shunts and how they compare
- Choosing between the two shunts
Lower gastrointestinal haemorrhage
From diverticula and angiodysplasia to colitis and ischaemia
- Lower gastrointestinal bleeding: why it is hard
- Management algorithm for lower gastrointestinal bleeding
- Working through the algorithm
- Operating for lower gastrointestinal bleeding
- On-table lavage
- Causes of lower gastrointestinal bleeding and their frequency
- Reading the lower gastrointestinal causes
- Diverticular disease
- What a colonic diverticulum actually is
- Diverticular bleeding and its treatment
- Bleeding from an inflamed diverticulum
- Angiodysplasia of the colon
- Telangiectatic lesions of colonic angiodysplasia
- Treating angiodysplasia
- Neoplasia as a cause of rectal bleeding
- Large ulcerated colonic tumour
- Bleeding from colonic polyps
- Large pedunculated polyp with bleeding
- Bleeding after polypectomy
- Bleeding from a polypectomy site
- Anal fissure
- Haemorrhoids
- Solitary rectal ulcer and anorectal varices
- Do not stop at the haemorrhoid
- Bleeding in inflammatory bowel disease
- Ulcerative colitis and Crohn's disease compared
- Cobblestone mucosa of Crohn's colitis
- Infectious colitis
- Non-steroidal anti-inflammatory drugs and the lower gut
- Radiation proctitis
- Telangiectasia of radiation proctitis
- Ischaemic colitis
- Confirming and treating ischaemic colitis
- Ulceration and submucosal haemorrhage in ischaemic colitis
Obscure and small bowel bleeding
What is left when upper endoscopy and colonoscopy are both normal
- Obscure bleeding
- Causes to consider in obscure bleeding
- Angiodysplasia of the small bowel
- Meckel's diverticulum
- Meckel's diverticulum at operation
- Why a Meckel's diverticulum bleeds
- Diagnosing and treating Meckel's diverticulum
- Small bowel diverticula that are not Meckel's
- Investigating and treating jejunal diverticula
- Small bowel tumours
- Ileal adenocarcinoma on computed tomography
Summary and references
The points worth carrying out of this topic
- Take-home points on assessment
- Take-home points on investigation
- Take-home points on treatment
- Traps worth remembering
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition