Upper GI bleed

Question 1

What is haematemesis?

Answer 1

Vomiting blood

Question 2

What is malaena?

Answer 2

Black stools

Question 3

What are causes of maleana?

Answer 3

GI haemorrhage/bleed

• Peptic ulcer disease
• Oesophageal varices
• Oesophagitis
• Gastritis
• Mallory–Weiss tear
• Neoplasm

Question 4

What is the mechanism behind malaena?

Answer 4

Bleeding from any cause in the upper gastrointestinal tract can result in melaena. It is often said that bleeding must begin above the ligament of Treitz; however, this is not always the case.

The black, foul-smelling nature of the stool is due to the oxidation of iron from the haemoglobin, as it passes through the gastrointestinal tract.

Question 5

What are common causes of upper GI bleeding?

Answer 5

• Peptic ulcers
• Mallory-Weiss tears
• Oesophageal varcies
• Gastritis/Gastric ulcers
• Drugs
• Oesophagitis
• Duodenitis
• Malignancy
• No Obvious cause

Question 7

What drugs can cause upper GI bleeding?

Answer 7

• NSAIDs
• Aspirin
• Steroids
• Thrombolytics
• Anticoagulants
• Alcohol

Question 8

What would you want to ask someone who was presenting with features of an upper GI bleed?

Answer 8

• Past GI bleeds
• Dyspespsia/known ulcers
• Known liver disease/oesophageal varices
• Dysphagia
• Vomiting
• Weight loss
• Drugs and alcohol use
• Serious comorbidities - CVS, Resp, hepatic/renal, malignancy

Question 9

What symptoms can occur in an acute upper GI bleed?

Answer 9

• Haematemesis
• Malaenia
• Dizziness/Psotural Syncope
• Abdo pain
• Dysphagia

Question 10

What signs might indicate someone is having an upper GI bleed?

Answer 10

1. Signs of liver disease - telangiectasia, purpura, jaundice
2. Signs of shock

• Hypotension (SBP <100mmHg)/Postural drop >20 mmHg
• Tacycardia
• Decreased JVP
• Decreased Urine output
• CRT>2s

Question 11

How would you manage someone having an acute GI bleed who was shocked?

Answer 11

ABCDE

• Protect airway, give O2
• Circulation assessment + 2 large bore cannulae
• Rapid crystalloid infusion - Consider Blood transfusion if severe shock
• Correct clotting abnormalities
• Catheterise and monitor urine output
• 15 minute obervations
• Urgent endoscopy
• Consider surgery if bleeding persists

Question 12

What bloods would you perform if someone presented in shock from an upper GI bleed?

Answer 12

• FBC
• U+E’s
• Clotting
• Glucose
• LFTs
• Crossmatch

Question 14

Why would you consider putting in a CVP monitor in someone recieving blood transfusion for an acute GI bleed?

Answer 14

To assess transfusion adequacy and overload on the heart

Question 15

When would you consider transfusion in someone with an upper GI bleed?

Answer 15

• Haemoglobin <80 g/L
• Patients with active bleeding

Question 16

What drugs would you want to check for (and stop) in someone having an acute GI bleed?

Answer 16

• NSAID’s
• Aspirin
• Clopidogrel
• Warfarin

Question 17

What can be used to control uncontrolled variceal bleeding?

Answer 17

• Trans-jugular intrahepatic porto-systemic shunt (TIPS)
• Balloon tamponade - Sengstaken-Blakemore tube - compresses the varcies

Question 18

What can cause Mallory-Weiss tears?

Answer 18

Sudden inicrease in intra-abdominal pressure

• Heavy coughing
• Heavy wretching/dry heaves

Question 19

How would you manage a varcieal bleed?

Answer 19

• IV Terlipressin
• Broad-spectrum IV antibiotics
• Endotherapy - variceal ligation/Sclerotherapy
• Correct any coagulopathies

Question 21

How would you manage bleeding ulcers?

Answer 21

• Haemostatic therapy - 2 out of 3/3 out of 3 of clips, cautery or adrenaline
• Post endoscopic PPI’s
• Consider H. Pylori erdication therapy
• Discontinue causative therapies - NSAIDs, aspirin

Question 22

What scoring systems are used to stratify Upper GI bleeds?

Answer 22

• Glasgow-Blatchford bleeding score - initial risk assessment of acute upper GI bleed
• Rockall score - identify patients at risk of complications following acute upper GI bleed

Question 23

What is coffee-ground vomit suggestive of?

Answer 23

Slow, intermittent bleed

Question 24

What is regarded as the point which distinguishes an upper GI bleed from a lower GI bleed?

Answer 24

Ligament of trietz

Question 25

Which does coffee-ground vomit indicate as a cause of haematemesis; peptic ulcers or variceal bleeding?

Answer 25

Peptic ulcers

Question 26

What would brisk haematemesis be indicative of as a cause?

Answer 26

• Variceal bleeding
• Actively bleeding gastro-duodenal ulcer

Question 27

What is haematochezia most commonly associated with; UGIB or LGIB?

Answer 27

LGIB - but can be upper in severe UGIB

Question 28

Why might urea be raised in an upper GI bleed?

Answer 28

As blood passes through the small bowel and is partially digested, it can result in an elevated urea and urea/Cr ratio - **equivalent to a large protein meal**

Question 29

What proportion of oesophageal varices will rebleed in a year?

Answer 29

60%