Acute Upper GI Bleed

Question 1

Acute Upper GI Bleed

Answer 1

may be caused by a wide variety of conditions but is most commonly due to either oesophageal varices or peptic ulcer disease.
ligament of Treitz (also known as the suspensory muscle of the duodenum) is found at the duodenojejunal flexure helps to distinguish between an upper GI bleed and a lower GI bleed

Question 2

Acute Upper GI Bleed

Answer 2

haematemesis (bright red or coffee ground)
melena (black tarry stools)
features associated with a particular diagnosis e,g,
oesophageal varices: stigmata of chronic liver disease
peptic ulcer disease: abdominal pain
a raised urea without rises in creatinine may be seen due to the ‘protein meal’ of the blood

Question 3

Differentials

Answer 3

Oesophagitis - GORD symptoms, small haemaatemsis
Cancer - small haematemesis, dysphagia, weight loss
Mallory Weiss tear - brisk small to moderate volume of bright red blood following a bout of repeated vomiting.

Question 4

Acute Upper GI Bleed: Management

Answer 4

Resuscitation
ABC, wide-bore intravenous access * 2
platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Endoscopy
should be offered immediately after resuscitation in patients with a severe bleed
all patients should have endoscopy within 24 hours

Management of non-variceal bleeding
NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Management of variceal bleeding
terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures