Upper GI bleed

Question 1

Common causes of Upper GI bleeding

Answer 1

Peptic ulcer disease (40%)

Gastritis (20%)

Mallory-Weiss tear (10%)

Oesophageal varices (5%)

Question 2

What is the Rockall score?

Answer 2

prediction of re-bleeding and mortality in patients with upper GI bleed

Question 3

Initial Rockall score pre-endoscopy

Answer 3

age

shock (BP, pulse)

comorbidities

Question 4

Final Rockall score post-endoscopy

Answer 4

active bleeding

visible vessel

adherent clot

Question 5

Pathophysiology of oesphageal varices

Answer 5

Portal HTN → dilated veins at sites of porto-systemic anastomosis: L. gastric and inferior oesophageal veins

30-50% with portal HTN will bleed from varices

Question 6

Mortality rate of oesphageal varices

Answer 6

25%

• ↑ with severity of liver disease.

Question 7

Prehepatic causes of portal HTN

Answer 7

pre-hepatic: portal vein thrombosis

Question 8

Hepatic causes of portal vein HTN

Answer 8

cirrhosis, schistosomiasis, sarcoidosis

Question 9

Post hepatic causes of portal vein HTN

Answer 9

Budd-Chiari, RHF, constrict pericarditis

Question 10

1st and 2nd line prevention of bleed in oesphageal varices

Answer 10

1st line: β-blockers, repeat endoscopic banding

2nd line: TIPSS

Question 11

Transjugular Intrahepatic Porto-Systemic Shunt (TIPSS)

Answer 11

• creates artificial channel between hepatic vein and portal vein → ↓ portal pressure.
• Colapinto needle creates tract through liver parenchyma and maintained by placement of a stent.
• Used prophylactically or acutely if endoscopic therapyfails to control variceal bleeding.

Question 12

Resuscitation of upper GI bleed patient

Answer 12

1. head-down
2. 100% O2
3. IV crystalloid infusion up to 1L
4. Bloods - FBC, U +Es (increase urea), LFTs, clotting, ABG, glucose

Question 13

Medical management of variceal bleed

Answer 13

1. terlipressin IV
2. prophylactic Abx (e.g. ciprofloxacin)

Question 14

Options for initiating haemostasis of a vessel or an ulcer via endoscopy

Answer 14

1. adrenaline injection
2. thermal/laser coagulation
3. fibrin glue
4. endoclips

Question 15

Varceal bleeding management via endoscopy

Answer 15

Any 2 of:

1. banding,
2. sclerotherpay (injecting salt into vessel, causing its collapse)
3. adrenaline,
4. coagulation

If not: balloon tamponade or TIPSS

Question 16

Post endoscopy management of upper GI bleeding

Answer 16

1. omeprazole
2. keep NBM for 24h

Question 17

Indications for surgery of upper GI bleeding

Answer 17

1. re-bleeding or bleeding despite transfusing 6 units
2. uncontrollable bleeding at endoscopy
3. initial Rockall score ≥3, or final >6.