Upper GI bleeding

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

Causes of portal HTN

Answer 7

pre-hepatic: portal vein thrombosis
hepatic: cirrhosis, schistosomiasis, sarcoidosis
post-hepatic - Budd-Chiari, RHF, constrict pericarditis

Question 8

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

Answer 8

1st line: β-blockers, repeat endoscopic banding

2nd line: TIPSS

Question 9

Transjugular Intrahepatic Porto-Systemic Shunt (TIPSS)

Answer 9

• 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 therapy
  fails to control variceal bleeding.

Question 10

Overview of management of upper GI bleeding

Answer 10

1. Resuscitate
blood if remains shocked
2. variceal bleed management
3. maintenance
4. urgent endoscopy
5. post-endoscopy

Question 11

Resuscitation of upper GI bleed patient

Answer 11

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 12

Medical management of variceal bleed

Answer 12

1. terlipressin IV

2. prophylactic Abx (e.g. ciprofloxacin)

Question 13

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

Answer 13

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

Question 14

Varceal bleeding management via endoscopy

Answer 14

I. 2 of:
1. banding,
2. sclerotherpay (injecting salt into vessel, causing its collapse)
3. adrenaline,
4. coagulation
II. balloon tamponade with Sengstaken-Blakemore tube
III. TIPSS if bleeding can’t be stopped endoscopically

Question 15

Post endoscopy management of upper GI bleeding

Answer 15

1. omeprazole
2. keep NBM for 24h
3. daily bloods
4. H.pylori testing
5. stop NSAIDs, steroids etc.

Question 16

Indications for surgery of upper GI bleeding

Answer 16

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