UGI bleed

Question 1

Causes of UGI bleeds

Answer 1

Peptic ulcer disease (35-50%)
Mallory-Weiss tear (15%)
Gastroduodenal erosions (8-15%)
Oesophagitis (5-15%)
Oesophageal varices (5-10%)
Other (malignancy, AVM)
Dieulafoy lesion (1.5%; torturous gastric arteriole)

Question 2

What classifies upper vs lower GI bleeds

Answer 2

Upper = before ligament of Treitz
Lower = after ligament of Treitz
Ligament of Treitz (suspends duodenal-jejunal flexure)

Question 3

investigations for UGI bleed

Answer 3

FBC
U&Es
LFT
Glucose
Clotting screen
Crossmatch 4-6 units

Question 4

Initial management for UGI bleed before knowing where the bleed is

Answer 4

1. A-E assessment
2. Resuscitation as appropriate
   - IV fluids
   - packed RBCs
   - Active bleeding, count <50x10^9 → platelets
   - Active bleeding +
   → FFP [PT/APTT >1.5x normal]
   → PCC [warfarin]
3. Risk assess
   - Blatchford score (pre): Urea, Hb, SBP, other
   - Rockall score (post): clinical bleeding + endoscopy results
   - Consider ICU/HDU referral
   - Catheterise and monitor urine output (aim >30ml/h)
   - Monitor vital signs every 15 minutes until stable → hourly
4. Endoscopy: immediately after resus (emergency) or <24h
5. Prophylaxis (variceal bleeding in portal HTN)  PO propranolol (40mg, BD, PO)
6. Pabrinex

Question 5

Management for gastric variceal bleeds

Answer 5

Medical: terlipressin IV 5 days + antibiotics IV

First line: endoscopic injection of butyl cyanoacrylate
Second line: TIPS (Transjugular Intrahepatic Portosystemic Shunt)

Question 6

Management for oesophageal varices

Answer 6

Medical: terlipressin IV 5 days + antibiotics IV

First line: endoscopic band ligation
Second line: Sengstaken-Blakemore tube + TIPSS (Trans-jugular Intrahepatic Portosystemic Shunt; definitive management)

Question 7

Management for non-variceal bleeds

Answer 7

Endoscopic:
- Mechanical clips ± adrenaline
- Thermal coagulation + adrenaline
- Fibrin/thrombin + adrenaline
PPI (only given once confirmed after endoscopy)