Acute Upper GI Bleeding

Question 1

Incidence and mortality of Acute Upper GI bleeding

Answer 1

-Incidence: 40-150/100000
-Mortality 10% overall, 7% new admissions and 25% existing inpatients

-Rising incidence of liver disease
-50% co-morbidity
-28%> 80y

Question 2

Causes of upper GI bleeding

Answer 2

-Oesophagitis (10%)- usually with hiatus hernia
-Peptic ulcer (35-50%)- NSAIDs, H. pylori
-Vascular malformations (5%)- teleangectasieas
-Aorto-duodenal fistula (0.2%)- aortic graft
-Varices (2-9%)- liver disease, portal vein thrombosis
-Mallory-Weiss tear (5%)- retching
-Cancer of stomach or oesophagus (2%)
-Gastric erosions (10-20%)- NSAIDs, alcohol
-Gastric antral vascular ectasia (GAVE)= watermelon stomach

Question 3

Management of non-variceal UGI bleeding

Answer 3

-Assessment and resuscitation
-Risk stratification
-Specialist referral
-Treatment
-Review

Question 4

Clinical presentation of UGI bleed

Answer 4

-Haematemesis
=Fresh red
=Altered blood with clots
=Coffee ground vomiting (viral illness, UTI, stroke, delirium, drug side effects?)

-Melaena
=Black tarry stool (microbiome changes)
=Rarely red/ purple blood (unless severe bleed)

-Fresh blood PR

-Haemodynamic collapse
=Syncope
=Hypovolaemic shock
=Lightheaded/ collapse/ cold/ clammy: hypovolaemia

-Symptoms of anaemia
=Lightheaded
=SOB
=Tired

Question 5

History of UGI bleed

Answer 5

-History
=Smoker
=Alcohol
=Risk factors for liver disease
=Colonic disease
=Use of aspirin, NSAIDs, antithrombotic, anticoagulants, nicorandil (anti-anginal, irritation of GI tract)
=Symptoms suggestive of ulcer/ previous ulcer/ surgery for ulcer

-Comorbidities
=Cardiovascular
=Respiratory
=Diabetes

-General fitness/ frailty
=Daily activities
=QOL

Question 6

Examination of UGI bleed

Answer 6

-Shock
=Pulse rate
=BP
=Cold peripheries
=Conscious level

-General
=Stigmata of chronic liver disease

-Abdominal
=Tenderness
=Mass
=Hepatosplenomegaly

-PR
-Raised urea with normal creatinine

Question 7

Resuscitation of UGI bleed

Answer 7

-ABC
-x2 IV cannula
-Blood: U&Es (GI bleed=large protein load), FBC, LFT, coagulation
-Crossmatch 2-4 units red cells
-IV fluids: 0.9% saline or plasmalyte, platelet transfusion if actively bleeding platelet count less than 50
-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

-NEWS
-Correct hypovolaemia
-Restore tissue perfusion
-Prevent multi-organ failure
-IV Crystalloids 500mls <15 minutes

PPI (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)

Question 8

Management of variceal bleeding

Answer 8

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

Question 9

Describe restrictive transfusion

Answer 9

-Target Hb 70-90g/L
-Increased mortality in major trauma patients if transfused
-Adverse outcomes in cardiac surgery if transfused
-Restrictive vs liberal
=All-cause mortality
=Rebleeding
=Transfusion

Question 10

What does a risk assessment include?

Answer 10

-Objectively quantify risk of death or intervention
=Early involvement of critical care teams
=Discharge of low-risk patients
=Benchmarking outcomes
=Clinical trials

-Blatchford score vs Rockall score (pre and post endoscopy components, stratify patients according to risk of death)

Question 11

Describe the Glasgow Blatchford Score

Answer 11

-Score 0-23
-For prediction of intervention
-Score 0-1 can be safely management as outpatients
-Urea, haemoglobin, HR, BP
Pts with score 0 considered for early discharge

Question 12

Why do people die from upper GI bleeding?

Answer 12

-Hypovolaemia due to rebleeding
-Non-bleeding related causes
=Malignancy
=MOF
=Respiratory
=Cardiac
=CNS

Question 13

Timing of endoscopy

Answer 13

-Stable patient: endoscopy <24 hrs
-Unstable/ ASA >3: endoscopy <12hrs
=Time spent resuscitating patients is important

Question 14

Describe Dual modality therapy

Answer 14

-Dilute epinephrine infection (historical)- vasodilation, clotting and coagulation temporarily
-Thermal modality (heater probe)/ mechanical modality (clips)

Question 15

Describe haemostatic powders

Answer 15

-Hemospray
-Nanopowder- topical procoagulant, primarily dehydration
-Physical barrier
-Rescue therapy

Question 16

When is trans catheter arterial embolisation used?

Answer 16

-When endoscopy fails
=Failed primary haemostasis
=Rebleeding
=Lower GI bleeding not visualised

-Patient unfit for laparotomy

Question 17

Post-endoscopy plan

Answer 17

-Ulcers requiring endoscopic therapy
=IV proton pump inhibitor 72 hours (80mg PPI then 8mg/hr) – reduces rebleeding and need for surgery

-H. Pylori eradication (if positive)

-Avoid NSAIDs if possible

-Plan for restarting antiplatelet or antithrombotic agents:
=aspirin: 3 days
=dual therapy: discuss with cardiology
=anticoagulants: 7* – 15 days (*7 days in high-risk thrombosis cases)

Question 18

Describe acute variceal UGI bleeding

Answer 18

-Bleeding from sites of porto-systemic anastomoses (collateral vessels)
-30-50% will bleed (oesophageal)
-70% <2y from diagnosis
-20% mortality from 1st bleed

Question 19

Comorbidities for bleeding oesophageal varices (SCARE)

Answer 19

-Sepsis (acute rise in portal pressure)
-Coagulopathy
-Ascites, electrolyte disturbance (hyponatraemia)
-Renal impairment
-Encephalopathy

Question 20

Factors increasing risk of variceal bleeding

Answer 20

-Varix pressure and size
-Wall tension (thin walled so fragile)
-Severity of liver disease

Question 21

Actions that improve survival in variceal haemorrhage

Answer 21

-Multi-organ support in a high dependency area
-Airway support (encephalopathy and shock)
-Antibiotics (translocation of bacteria)= ceftriaxone
-Fluid balance and electrolytes
-Vasopressors- terlipressin 3-5 days
-Renal function
-Nutritional support (catabolic, poor muscle function)

Question 22

Post-bleed management of variceal bleeding

Answer 22

-Repeat banding weekly until varices eradicated
-Drugs + sclerotherapy
-Gastric varices= glue/ thrombin infection
-Non-selective beta-blocker
=Propranolol 40mg
=Carvedilol 6.25-12.5mg daily
=Terlipressin (reduce portal hypertension) and antibiotics (5 days)
-Endoscopic surveillance for recurrence

Question 23

Indications of cotrimoxazole in GI context

Answer 23

-Spontaneous bacterial peritonitis
=Started as long-term prophylactic

Question 24

Pneumonic for causes of GI bleed

Answer 24

TOP TO BOttom

-Tear (Mallory-Weiss)
-Oesophageal/ gastric varices
-Peptic ulcer disease

-Tumours (oesophageal/ gastric0
-Oesophagitis/ gastritis

-Boerhaave’s syndrome
-0dd vascular formation (angiodysplasia)

Question 25

Questions to ask about acute haematemesis event

Answer 25

-Is the airway compromised?
-How much did they bring up?
-What are the vital signs (haemodynamic compromise)?
-What is their conscious level?
-What did recent blood tests show (INR needing vitamin K)?
-IV access?
-Do they have valid group and save (blood transfusion)?
-Catheter?
-AMPLE= allergies, medication, PMH, Last meal, Events leading up to

Question 26

Resuscitation fluid in liver failure patients

Answer 26

Hartmann’s over 0.9% saline as that would worsen ascites