Upper GI Bleeding

Question 1

What are the symptoms of an upper GI bleed?

Answer 1

• Haematemesis,
• Coffee ground vomit,
• Melaena.
  These symptoms occur due to bleeding from oesophagus, stomach or duodenum

Question 2

What is the key investigation of an upper GI bleed

Answer 2

• Endoscopy

Question 3

What are the causes of an upper GI bleed?

Answer 3

• Peptic ulcer,
• Oesophagitis.
• Gastritis
• Dunodenitis
• Varices (highest mortality)
• Malignancy,
• Mallory-Weiss tear

Question 4

What are the causes of a peptic ulcer?

Answer 4

Excess acid, NSAIDs or H.pylori. Duodenal ulcers are more common. In gastric ulcers malignancy is a possible cause so requires biopsy

Question 5

What is a Mallory-Weiss tear?

Answer 5

Tear of the lower oesophagus but above the gastroesophageal junction. Can be caused by violent coughing or vomiting

Question 6

What is the management of an upper GI bleed?

Answer 6

Resuscitate - Look at pulse and BP. Gain IV access for fluids and bloods (Hb and urea). Lie flat and oxygen.
Risk assessment and timing of endoscopy - High risk needs emergency endoscopy. Medium risk requires admission with next day endoscopy and low risk can be managed as out patient
Give drug therapy and transfusion

Question 7

What are the different risk assessment scores used in an upper GI bleed?

Answer 7

• Endoscope = Rockall which considers: age, shock, comorbidities, diagnosis and stigmata.
• Clinical = Admission Rockall which considers age, shock and comorbidities or Glasgow Blatchford.

Question 8

What factors are included in the Glasgow Blatchford score?

Answer 8

• Blood urea,
• Haemoglobin,
• Systolic BP,
• Pulse,
• Presence of melaena,
• Presence of syncope,
• Heart failure,
• Hepatic disease

Question 9

A Glasgow Blatchford score equal too or less than 1 indicates?

Answer 9

The patient is at low risk for a poor outcome and can be discharged for an outpatient endoscopy

Question 10

What causes of upper GI bleeds require endoscopic treatment?

Answer 10

Active bleeds, non bleeding visible vessel and clots require treatment whereas dots/clean bases do not need endoscopic treatment

Question 11

What are the different endoscopic therapies for an upper GI bleed?

Answer 11

• Adrenaline injection (causes vasoconstriction but only temporarily so does require adjunctive treatment)
• Heater probe (Cauterise small bleeds)
• Endoscopic clips (big bleeds)
• Haemostatic powders (temporarily coagulates, used when initial therapy is failing and you need time)

Question 12

What treatment can be done if an upper GI bleed hasn’t been successfully treated endoscopically.

Answer 12

Radiological embolisation of a bleeding vessel.
Emergency surgery (very rare)

Question 13

What drug can reduce re-bleeding and mortality in high risk patients if given post-endoscopy?

Answer 13

PPIs

Question 14

Explain the management of an upper GI bleed if patient is on aspirin or NSAIDs

Answer 14

• Stop NSAID.
• Continue low does aspirin after haemostasis has been achieved (and add ppi)

Question 15

What is the management of patients with an upper GI bleed on clopidogrel/warfarin/DOAC

Answer 15

• Stop and assess risks once haemostasis is achieved. Aim is to restart meds as high mortality from CV disease

Question 16

Explain the use of blood products in the management of an upper GI bleed

Answer 16

• Transfuse blood only if Hb is below 7-8g/dL
  Transfuse platelets only if patient is activley bleeding and has platelets below 50x10(9)/L
  Give FFP is INR>1.5
  Give vitamin K and prothrombin complex concentrate if patient is on warfarin and actively bleeding.

Question 17

How do varices arise?

Answer 17

Liver cirrhosis causes increased hepatic resistance due to vascular occlusion and increased vascular tone. This results in increased portal pressure. This causes dilitation of existing oesophageal veins and by angiogenesis.

Question 18

Why has there been a rise in the number of varices?

Answer 18

Due to increased alcohol intake, hepatitis C and Non-alcoholic fatty liver disease (NAFLD)

Question 19

What is the treatment of acute variceal bleeding?

Answer 19

Resuscitation - Restore circulating volume, transfuse if Hb<7g/dL and consider airway protection.
Treatment - Early antibiotics, vasopressors (terlipressin), endoscopic band ligation and trans-jugular intrahepatic stent shunt (TIPS) if needed

Question 20

Explain the management on uncontrolled variceal bleeding

Answer 20

• Sengstaken tube (balloon tamponade) for temporary control. This can be used before a TIPS as TIPS takes a while to set up.
• TIPS is mainstay
• Surgical shunt/transection is now rarely used.
• If haemodynamically unstable think major haemorrhage protocol.

Question 21

What is the prophylaxis and prevention of re-bleeds for varices

Answer 21

Beta blockers like carvedilol or band ligation