Upper GIT haemorrhage

Question 1

Causes of acute upper GIT haemorrhage

Answer 1

• Oesophagus: Oesophageal varices, Mallory-Weiss tear
• Stomach: Gastric ulcer, erosive haemorrhagic gastritis
• Duodenum: Duodenal ulcer, erosive duodenitis
• Other uncommon causes: tumours, stomal or anastomotic ulcers, vascular malformation, oesophagitis or oesophageal ulcers

Question 2

Typical history of peptic ulcer disease

Answer 2

History of periodic dyspepsia related to meals or excessive analgesic ingestion (Not sensitive or specific)

Question 3

History given for a mallory-weiss tear

Answer 3

History of an episode of repeated vomiting

Question 4

In a patient with excessive alcohol intake and known liver disease, what is the likely cause of upper GIT bleeding

Answer 4

oesphageal varices

Question 5

What is maelena and what does it indicate

Answer 5

• Black tarry stools which is formed by blood mixed with acid
• Indicates that the source of bleeding is in the upper GIT tract

Question 6

In severely shocked patients, what should be mandatory

Answer 6

• Central venous pressure line and urinary catheter
• Baseline haematolological and biochemical investigations must be urgently requested together with cross-matching of blood

Question 7

How is the resuscitation of patients with suspected liver disease different to other patients with upper GIT bleed

Answer 7

Patients with underlying liver disease should not be given sodium containing crystalloid solutions. They should be resuscitated only with blood, 5% dextrose, given fresh frozen plasma to replenish clotting factors and receive ocreotide to lower portal pressure

Question 8

Uses and disadvantages of use of nasogastric tube in patients with upper GIT haemorrhage

Answer 8

• Uses: Early identification of recurrent or continued bleeding, the performance of gastric lavage and emptying the stomach contents before endoscopy
• Disadvantages: Unreliable in detecting rebleeding, uncomfortable for the patient, may cause rather than prevent aspiration in the elderly patients

Question 9

Diagnostic procedure of choice for upper GI bleeding

Answer 9

Endoscopy

Question 10

When is urgent endoscopy indicated

Answer 10

-Oesophageal varices are suspected or where there are signs of continuing haemorrhage. High risk patients should undergo endoscopy as soon as they are stabilised

Question 11

If an urgent endoscopy is not indicated, when should it be performed

Answer 11

-Where urgent endoscopy is not indicated, patients should undergo a full diagnostic endoscopy within 12-24 hours of admission when they are clinically stable and have been fully resuscitated

Question 12

Forrest classification of peptic ulcers (High risk)

Answer 12

• IA: Spurting blood (visible vessel)
• IB: ooze blood (non-visible vessel)
• IIA: non bleeding visible vessel
• IIB: Adherent clot

Question 13

Forrest classification of peptic ulcer (low risk)

Answer 13

IIC: pigmented spot
III: clean ulcer base

Question 14

When is angiography indicated

Answer 14

Indicated in number of patients who continue to bleed and when endoscopy has failed to disclose a likely bleeding site. Bleeding from obscure and uncommon sites such as the liver, pancreatic duct, small bowel and colon may be identified.

Question 15

What risk stratification score is used in patients with upper GIT bleeding, what score indicates increased risk of bleeding and death

Answer 15

• Rockall risk score

- A total score of over two indicates increased risk of bleeding and death

Question 16

Parameters measured in the Rockall risk score

Answer 16

• Age
• Haemodynamic status
• Co-morbidities
• Endoscopic diagnosis
• Stigmata of recent haemorrhage

Question 17

When treating bleeding peptic ulcers, what is the goal of medical therapy

Answer 17

Increase the intragastric pH to above 6

Question 18

Initial management of bleeding peptic ulcer

Answer 18

• Assess haemodynamic status
• Obtain FBC, U and E, INR
• Commence resuscitation
• Consider IV PPI
• Perform endoscopy

Question 19

Patients at risk for rebleeding of peptic ulcer

Answer 19

• Age over 60
• Shock on admission
• Endoscopic stigmata of recent bleeding
• Large ulcers (>2 cm)
• Lesser curve gastric and posterior duodenal bulb ulcers

Question 20

How long should high risk patients be obeserved in the hospital for following bleeding peptic ulcer

Answer 20

minimum of three days

Question 21

endoscopic therapy for bleeding peptic ulcer

Answer 21

• Injections with diluted adrenalin (1: 10 000)

- Bipolar thermal coagulation

Question 22

Who should angiography and embolisation be reserved for in bleeding peptic ulcer disease

Answer 22

-patients who failed endoscopic treatments and are poor candidates for surgery

Question 23

Indications for surgery in bleeding peptic ulcer disease

Answer 23

• Exanguinating haemorrhage
• Associated perforation
• Failed endoscopic therapy of active bleeding in shocked patients
• Recurrent bleeding after endoscopic therapy
• Patients at risk for rebleeding where endoscopic therapy is not available

Question 24

management of high risk patients with bleeding peptic ulcer disease

Answer 24

• Admit to high care unit
• Endoscopic therapy
• Commence IV PPIs
• initiate oral intake of clear fluids 6 hours after endoscopic haemostastis
• transition to oral PPIs
• perform testing for H. pylori, initiate eradiacation therapy if result is possible

Question 25

Management of low risk patients with bleeding peptic ulcer disease

Answer 25

- No endoscopic haemostasis - commence oral PPI - Perform testing for H. Pylori - Initiate eradication therapy if result is positive - Consider early discharge from hospital