Acute Upper Gastrointestinal Bleeding

Question 1

What are the causes of acute upper gastrointestinal bleeding?

Answer 1

• Peptic ulcer disease
• Gastroduodenal erosions
• Oesophagitis
• Mallory-Weiss tear
• Varices
• Upper GI malignancy
• Vascular malformations

Question 2

What are the potential sources of swallowed blood?

Answer 2

• Facial trauma
• Nose bleed
• Haemoptysis

Question 3

What are the symptoms of an upper GI bleed?

Answer 3

• Haematemesis
• Melaena
• Dizziness
• Fainting
• Abdominal pain
• Dysphagia

Question 4

What are the signs of acute upper gastrointestinal bleeding?

Answer 4

• Hypotension (in young people, likely to be postural only)
• Tachycardia
• Decreased JVP
• Decreased urine output
• Cool and clammy
• Signs of chronic liver disease

Question 5

Give three signs of chronic liver disease

Answer 5

• Telangiectasia
• Purpura
• Jaundice

Question 6

What should the focus be on in the management of acute upper GI bleeding?

Answer 6

Circulation

Question 7

Give an example of a method of risk stratification in acute upper GI bleeding?

Answer 7

Rockall score

Question 8

What are the signs that a patient with an acute upper GI bleed is shocked?

Answer 8

• Peripherally cool/clammy
• Capillary refill time >2s
• Urine output <0.5mL/kg/h
• Decreased GCS or encephalopathy
• Tachycardic
• Systolic BP <100mHg, or postural drop of >20mmHg

Question 9

How is a patient in shock following an acute upper GI bleed managed?

Answer 9

1. Protect airway, and keep NBM
2. Insert two large-bore cannulae
3. Urgent bloods
4. If signs of grade III or IV shock, give blood. Otherwise, continue IV fluids to maintain BP, and transfuse, e.g. if Hb <70
5. Correct clotting abnormalities
6. Consider referral to ICU or HDU, and consider CVP line to guide fluid replacement
7. Catheterise and monitor urine output
8. Monitor vital signs every 15 minutes until stable, then hourly
9. Notify surgeons of all severe bleeds
10. Urgent endoscopy at earliest possible point after adequate resuscitation

Question 10

What urgent bloods should be done when a patient is in shock following an acute upper GI bleed?

Answer 10

• FBC
• U&E
• LFT
• Glucose
• Clotting screen
• Blood typing

Question 11

What blood type should be given to patients with grade III or IV shock with acute upper GI bleeding?

Answer 11

Group specific, or O -ve until crossmatch done

Question 12

How are clotting abnormalities corrected in a shocked patient following an acute upper GI bleed?

Answer 12

• Vitamin K
• FFP
• Platelet concentrate

Question 13

What central venous catheter pressure should be aimed for in a shocked patient following an acute upper GI bleed?

Answer 13

>5cmH₂O

Question 14

When might the CVP result be misleading?

Answer 14

Ascites or CCF

Question 15

What urinary output should be aimed for in a shocked patient following upper GI bleeding?

Answer 15

>30mL/h

Question 16

Why is an urgent endoscopy required in shocked patients with acute upper GI bleeding?

Answer 16

Diagnosis, with or without control of bleeding

Question 17

In what situations should you avoid giving saline as the fluid in volume restoration after acute upper GI bleeding?

Answer 17

Cirrhosis/varices

Question 18

Give two examples of things that would give rise to suspicion of varices in a patient with acute upper GI bleeding

Answer 18

• Known history of liver disease
• Alcohol excess

Question 19

What should be done in a patient with acute upper GI bleeding and suspicion of varices?

Answer 19

• IV terlipressin (1-2mg/6h for 3 days)
• Broad-spectrum IV antibiotics

Question 20

What can be done if endoscopic control of upper GI bleeding fails?

Answer 20

Surgery or emergency mesenteric angiography/embolisation

Question 21

What can be used in uncontrolled oesophageal variceal bleeding?

Answer 21

Sengstaken-Blakemore tube