Acute Upper GI Bleeding

Question 1

What clinical features can be seen?

Answer 1

• haematemesis
• maleana
• raised urea - due to ‘protein meal’ of blood

Question 2

Oesophageal causes

What clinical features would you see in the following:

1. oesophageal varices
2. oesophagitis
3. cancer
4. mallory-weiss tear

Answer 2

1. • large volume of fresh blood
   • rebleeds common
     +/- haemodynamic compromise
2. • small volume of fresh blood - streaky vomit
     +/- history of GORD-like symptoms
3. • small bleed (unless erosion of major vessels which would cause considerable haemorrhage + haematemesis)
   • dysphagia
   • weight loss
4. small / medium volume of bright red blood following repeated vomiting

Question 3

Gastric causes

What clinical features would you see in the following:

1. Gastric ulcer
2. gastric cancer
3. Dieulafoy lesion
4. Diffuse erosive gastritis

Answer 3

1. • small volume bleeds often presenting as iron deficient anaemia (unless erosion of major vessels)
2. • frank haematemesis or blood mixed with vomit
   • preceding dyspepsia and weight loss
3. AV malformation causing large bleed with no preceding symptoms
4. • haematemesis
   • epigastric pain / discomfort
   • cause e.g. NSAID usage

Question 4

Duodenal Causes

What clinical features would you see in the following:

1. duodenal ulcer
2. aorta-enteric fistula

Answer 4

1. • haematemesis
   • malaena
   • epigastric pain / discomfort

NOTE: often posterior sited and may erode gastroduodenal artery

2. previous AAA repair and major haemorrhage

Question 5

Describe the score used:

1. to first assess whether patients require admission
2. after endoscopy to assess risk of bleeding / mortality

Answer 5

1. Glasgow-Blatchford

2. Rockall

Question 6

Resuscitation

When should the following be given:

1. platelet transfusion
2. FFP
3. prothrombin complex concentrate

Answer 6

1. platelets <50
2. fibrinogen, prothrombin time or activated thromboplastin time 1.5x normal
3. major bleed in warfarin

Question 7

How should variceal bleeding be managed:

1. acutely
2. prophylactically

Answer 7

1. pre-endoscopy: terlipressin + prophylactic antibiotics

oesophageal: endoscopic band ligation
gastric: NB2C injection

if persists require transjugular intrahepatic portosystemic shunts

2. non-selective beta blocker e.g. propanolol

Question 8

What intervention should be done

1. for all patients
2. further bleeding

Answer 8

1. endoscopy within 24 hrs
   (Immediate if severe)
2. endoscopy / interventional radiology / surgery