Upper GI bleeds

Question 1

Causes of upper GI bleeds [7]

Answer 1

Peptic ulcers

Oesophageal varices

Mallory-Weiss tear/ Boerhaave’s

Leiomyoma

Dieulafoy lesion

Gastritis/ Oesophagitis

Question 2

Rockall score

Answer 2

Scoring tool that calculates risk of adverse events following high

Variables:

• Age
• Co-morbidity
• Diagnosis
• Shock
• Evidence of bleeding

Interpretation

• <3= good prognosis
• > 8= high risk of mortality

Question 3

Glasgow-blatchford score

Answer 3

Assesses likelihood of medical intervention (blood transfusion/ endoscopic evaluation)

Variables: Blood urea, Hb, systolic BP, HR, melaena, syncope, heaptic disease, cardiac failure

> 6= >50% need for intervention

Question 4

Acute management of upper GI bleed

Answer 4

1. Resuscitation
2. Endoscopy
   - Haemostasis if active bleeding
3. IV PPI 72 hours

If re-bleed

• Surgical intervention–>laparotomy
• Endoscopic haemostasis

No rebleed

• H pylori eradication
• Stop NSAIDs

Question 5

Balloon tamponade

• Indications
• Contraindications
• Complications

Answer 5

Indications

• Massive bleed, in unstable patients
• Endoscopy not available or effective
• Vasoactive agent fails.

Contraindications

• Oesophageal strictures
• Recent oesophageal or gastric surgery

Complications

• Airway obstruction
• Eoesophageal rupture
• Aspiration pneumonitis
• Pain
• Ulceration: lips, mouth, tongue.
• erosions

Question 6

Surgical intervention of peptic ulcer

Answer 6

Over-sew of bleeding ulcer

IR embolization
- Transcatheter arterial embolisation

Emergency gastrectomy
- RARE

Question 7

Stress ulcers

Answer 7

Reduction in mucosal blood flow

• Due to physiological stress
• Can happen in those critically ill

Question 8

Duodenal vs gastric ulcer

Answer 8

Duodenal

Question 9

Murphy’s sign

Answer 9

USS/ Hand pressing on RUQ and asking Pt to breathe in if painful
- Positive= localised guarding

Causes
- Acute Cholecystitis

Question 10

Peptic ulcer

• Definition
• Classifications

Answer 10

Mucosal breach due to mucosal breakdown in stomach/ duodenum.
- Ulcer in columnar mucosa of lower oesophagus, stomach, duodenum or small bowel

Classifications

• Gastric (type 1, body and fundal)
• Duodenal and gastric (Type 3, prepyloric)
• Atypical

Question 11

Gastric ulcer (type 1 ulcer)

• Risk factor
• Associations
• Symptoms

Answer 11

M>F= 3:1
- Age 50

Associations

• H. pylori (45%)
• NSAIDs
• Alcohol
• Smoking
• Low acid secretion

Symptoms

• Epigastric pain worse with food
• weight loss, anorexia

Question 12

Duodenal/ type 2 gastric ulcer

• Risk factor
• Associations
• Symptoms

Answer 12

M>F= 5:1
- 25-30 years

Associations

• H.pylori (85%)
• NSAIDs
• Smoking
• High acid secretion

Duodenal symptoms

• Epigastric pain relieved by food
• Precipitated by hunger, central back radiation
• Pain is often in early hours of the morning

Question 13

Atypical ulceration

• Description/ cause
• Associations

Answer 13

Atypical sites of gastric secretion
- Ectopic gastric mucosa in Meckel’s diverticulum

Abnormal high levels of acid secretion (Zollinger-Ellison syndrome)

Associations

• Ulcers that fail to respond to max medical therapy
• Multiple ulcers
• Ulcers in abnormal locations (distal duodenum, small bowel)

Question 14

Complications of peptic ulcer

Answer 14

Upper GI bleed

Iron deficient anaemia

Perforation

Chronic scarring around pylorus causig gastric outlet obstruction

Question 15

H. Pylori eradication therapy

Answer 15

Triple therapy

• Metronidazole
• Clarithromycin
• PPI

Question 16

Surgical management of peptic ulcer

• Indication
• Procedures

Answer 16

Indications
- Gastric outlet obstruction not responsive or suitable for endoscopic dilation.

• Failure to respond to max medical treatment with severe symptoms
• emergency: perforation, bleeding

Procedures

• Pyloroplasty
• Partial gastrectomy

Question 17

Management of variceal bleed

Answer 17

1. Resucitation
   - IV vasopressin/ analogues
2. Endoscopic banding