Upper GI Bleeds

Question 1

What is the anatomical point which seperates upper GI bleeds from lower GI?

Answer 1

• Ligament of Trietz

Question 2

What are the common causes of upper GI bleeds?

Answer 2

• PUD (most common)
• Gastroduodenal erosions
• Mallory-Weiss tear
• Oesophageal varices
• Gastritis, oesophagitis, duodenitis
• NSAIDs, aspirn, steroids, thrombolytics, anticoagulants
• Malignancy

Question 3

What are the rare causes of upper GI bleeds?

Answer 3

• Bleeding disorders
• Angiodysplasia
• Meckel’s diverticulum

Question 4

What are the causes of Haematemesis?

Answer 4

• Emergency
  
  • Gastric ulceration
  • Oesophageal varices - portal hypertension due to alcoholic liver disease
• Non-emergency
  
  • Mallory-weiss tear
  • Oesophagitis - due to GORD, candida
  • Meckel’s diverticulum, gastritis, gastric malignancy

Question 5

What is the presentation of upper GI bleeds?

Answer 5

• Haematemesis/Malena
• Epigastric discomfort
• Sudden collapse

Question 6

What scoring system is used in suspected upper GI bleeds?

How does this scoring system help?

Answer 6

• Glasgow-Blatchford score
• Risk-stratifies pt with upper GI bleed using clinical and biocehmical parameters
• If score >5, need intervention

Question 7

Why do you get a raise in urea in upper GI bleed?

Answer 7

• blood in GI tract gets broken down by acid and digestive enzymes
• urea is one of the byproducts
• urea absorbed in intestine

Question 8

What are the parameters measured in Glasgow-Blatchford score?

Answer 8

• Drop in Hb
• Rise in urea
• Systolic BP
• Heart rate
• Melaena
• Syncopy
• Known hepatic/cardiac failure

Question 9

What is the Rockall score used for?

Answer 9

• calculate risk of rebleeding and mortality for patients after endoscopy

Question 10

What parameters are used in the Rockall score?

Answer 10

• Age
• Features of shock (e.g. tachycardia or hypotension)
• Co-morbidities
• Cause of bleeding (e.g. Mallory-Weiss tear or malignancy)
• Endoscopic stigmata of recent haemorrhage such as clots or visible bleeding vessels

Question 11

How would you Mx upper GI bleeds?

Answer 11

• Protect airway & give high-flow O2
• Insert 2 large bore for IV access and bloods
• FBC, U&E, LFT, glucose, clotting screen, crossmatch 4-6units
• urinary catheter
• CXR, ECG, ABG
• Central venous line - monitor fluid replacement
• Transfuse c cross matched blood if Hb < 70g/L
• Correct clotting abnormalities (vit K, FFP, platelets)
• Terlipressin and broad spec abx if varices suspected
• Arrange urgent endoscopy
• Surgery or emergency mesenteric angiography if endoscopy fail to control

Question 12

What is the definitive tx for upper GI bleeds?

Answer 12

• OGD - banding, cautherisation

Question 13

How would you assess a patient with acute upper GI bleed?

Answer 13

• Check whether the pt is shocked
  
  • Peripherally cool/clammy
  • cap refill time >2s
  • UO <0.5mL/kg/hr
  • low GCS
  • Tachycardic
  • Systolic BP <100

Question 14

What is a Terlipressin?

Answer 14

• Vasoactive drug for mx of low BP

Question 15

What are the key facts to ascertain when taking a Hx of haematemesis?

Answer 15

• Timing, frequency, volume of bleeding
• Hx of dyspepsia, dysphagia, odynophagia
• PMH alcohol, smoking
• Steroids, NSAIDs, anticoagulants, biphosphonates

*biphosphonates (osteoporosis medications) irritates oesophagus and cause gastric ulcer.

Question 16

What Ix would you order for upper GI bleed?

Answer 16

• Bloods
  
  • Routine
  • LFT
  • G+S & crossmatch
  • VBG
• Imaging
  
  • CXR - pneumoperitoneum
  • OGD - Definitive
  • CT Abdo c IV contrast (triple phase)

Question 17

How would you mx upper GI bleed in an acute setting?

*prioritise circulation

Answer 17

• A-E
• Fluid challenge - avoid saline in cirrhosis/varices
• Urinary catheter
• Blood transfusion
• FFP, PCC, platelets, Vit K - correct clotting abnormalities
• If varices suspected
  
  • Terlipressin 1-2mg/6h (vasopressor) or Octrotide(Somatostatin analogue) - reduce splanchnic bloodflow
  • Broad spec Abx - quinolones
  • OGD banding
  • Sengstaken-Blakemore tube - uncontrolled bleeding
  • TIPSS - if above fails
• If PUD
  
  • Adrenaline injection
  • High dose PPI - Omeprazole 40mg IV - to reduce acid secretion
    
    • Only give after endoscopy
  • Cauterisation
• Prophylaxis for variceal haemorrhage
  
  • Propanolol
  • endoscopic variceal band ligation (EVL) + PPI

Question 19

What are the indications for surgery with upper GI bleeds?

Answer 19

• Patients > 60 years
• Continued bleeding despite endoscopic intervention
• Recurrent bleeding
• Known cardiovascular disease with poor response to hypotension