UGI bleeding

Question 1

Clinical features ugi bleed

Answer 1

haematemesis, coffee ground
melena, black and tarry
a raised urea may be seen due to the ‘protein meal’ of the bloodfeatures associated with a particular diagnosis e,g,
oesophageal varices: stigmata of chronic liver disease
peptic ulcer disease: abdominal pain

Question 2

UGI bleed Oesophageal causes

Answer 2

Oesophageal varices
Oesophagitis
Cancer
Mallory Weiss tear

Question 3

Oesophageal varices features

Answer 3

• large volume of fresh blood.
• Swallowed blood may cause melena.
• haemodynamic compromise.
• May stop spontaneously but re-bleeds are common until appropriately managed.

Question 4

Oesophagitis features

Answer 4

• Small volume of fresh blood, often streaking vomit.
• Malena rare.
• Often ceases spontaneously.
• Usually history of antecedent GORD type symptoms.

Question 5

Cancer features

Answer 5

• small volume of blood, except as a preterminal event with erosion of major vessels.
• dysphagia and constitutional symptoms such as weight loss.
• May be recurrent until malignancy managed.

Question 6

Mallory Weiss tear features

Answer 6

• Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting.
• Malena rare.
• Usually ceases spontaneously.

Question 7

Gastric causes

Answer 7

Gastric ulcer
Dieulafoy lesion
Diffuse erosive gastritis

Question 8

Gastric ulcer

Answer 8

• Small low volume bleeds are more common so would tend to present as iron deficiency anaemia.
• Erosion into a significant vessel may produce considerable haemorrhage and haematemesis
• Pain soon after meals, not relieved by eating, eating makes it worse . As food passes into the stomach it irritates the ulcer (due to acid secretion)

Question 9

Dieulafoy lesion

Answer 9

Often no prodromal features prior to haematemesis and melena, but this arteriovenous malformation may produce quite a considerable haemorrhage and may be difficult to detect endoscopically
often symptomatic in men with alcohol histories, cardiovascular disease including hypertension, diabetes, or chronic kidney disease.

Question 10

Diffuse erosive gastritis

Answer 10

Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise

Question 11

Duodenual causes

Answer 11

Duodenal ulcer
Aorto-enteric fistula

Question 12

Features of Duodenal ulcer

Answer 12

• usually posteriorly sited and may erode the gastroduodenal artery
• may present with haematemesis, melena and epigastric discomfort.
• pain 2-3h after meals (when the pyloric sphincter relaxes to allow the acidic food contents into the duodenum), pain relieved by eating.

Question 13

Aorto-enteric fistula

Answer 13

In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.

Question 14

Risk assessment

Answer 14

the Glasgow-Blatchford score at first assessment helps clinicians decide whether patient patients can be managed as outpatients or not
the Rockall score is used after endoscopy- provides apercentage risk of rebleeding and mortality

Question 15

Resuscitation

Answer 15

• ABC, wide-bore intravenous access * 2
• platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
• fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
  . prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Question 16

Bloods

Answer 16

Send blood for FBC, U&Es (raised urea suggests digestion of blood), LFTs, VBG, clotting and 2 group and saves.

Question 17

Management of non-variceal bleeding

Answer 17

endoscopic
PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Question 18

Management of variceal bleeding

Answer 18

terlipresin
abx
Endoscopic banding
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures