Acute Upper GI Bleeding

Question 1

What is acute upper gastrointestinal most commonly caused by?

Answer 1

Oesophageal varices
Peptic ulcer disease

Question 2

Give 2 symptoms of acute upper gastrointestinal bleeding

Answer 2

Haematemesis (often bright red, sometimes coffee ground)
Melena (black + tarry)

Question 3

What features may indicate the underlying cause of acute upper GI bleeding?

Answer 3

Stigmata of chronic liver disease: Oesophageal varices
Abdo pain: PUD

Question 4

What may be seen on bloods in an acute upper GI bleed?

Answer 4

Raised urea due to the ‘protein meal’ of the blood

Question 5

List 4 oesophageal causes of acute upper GI bleeding

Answer 5

Oesophageal varices
Oesophagitis
Cancer
Mallory Weiss tear

Question 6

Describe presentation of an upper GI bleed due to oesophageal varices

Answer 6

Usually a large volume of fresh blood.
Swallowed blood may cause melena.
Often a/w haemodynamic compromise.
May stop spontaneously but re-bleeds are common until appropriately managed.

Question 7

Describe presentation of an upper GI bleed due to oesophagitis

Answer 7

Small volume of fresh blood, often streaking vomit.
Malena rare.
Often ceases spontaneously.
Usually hx of antecedent GORD type Sx

Question 8

Describe presentation of an upper GI bleed due to cancer

Answer 8

Usually small volume of blood, except as a preterminal event with erosion of major vessels.
Often associated Sx of dysphagia + constitutional Sx e.g. WL.
May be recurrent until malignancy managed.

Question 9

Describe presentation of an upper GI bleed due to Mallory Weiss tear

Answer 9

Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting.
Malena rare.
Usually ceases spontaneously.

Question 10

List 4 gastric causes of acute upper GI bleeding

Answer 10

Gastric ulcer
Gastric cancer
Dieulafoy lesion
Diffuse erosive gastritis

Question 11

Describe presentation of an upper GI bleed due to a Gastric ulcer

Answer 11

Small, low vol bleeds are more common so tend to present as IDA
Erosion into a significant vessel may produce considerable haemorrhage + haematemesis.

Question 12

Describe presentation of an upper GI bleed due to gastric cancer

Answer 12

May be frank haematemesis or altered blood mixed with vomit.
Usually prodromal features of dyspepsia + constitutional Sx.
Amount of bleeding variable but erosion of major vessel may cause considerable haemorrhage.

Question 13

Describe presentation of an upper GI bleed due to Dieulafoy lesion

Answer 13

Often no prodromal features prior to haematemesis + melena
but this AV malformation may produce quite a considerable haemorrhage
May be difficult to detect endoscopically

Question 14

Describe presentation of an upper GI bleed due to diffuse erosive gastritis

Answer 14

Usually haematemesis + epigastric discomfort. Usually there is an underlying cause e.g. recent NSAID usage.
Large vol haemorrhage may occur with considerable haemodynamic compromise

Question 15

Name 2 duodenal causes of acute upper GI bleeding

Answer 15

Duodenal ulcer
Aorto-enteric fistula

Question 16

Describe presentation of an upper GI bleed due to a duodenal ulcer

Answer 16

Usually posteriorly sited + may erode the gastroduodenal artery.
However, ulcers anywhere in the duodenum may present with haematemesis, melena + epigastric discomfort.

Pain of a duodenal ulcer is slightly different to that of gastric ulcers + often occurs several hours after eating.

Periampullary tumours may bleed but these are rare.

Question 17

Describe presentation of an upper GI bleed due to aorta-enteric fistula

Answer 17

In patients with previous abdo aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage a/w high mortality.

Question 18

Describe use of risk assessment in acute upper GI bleeding

Answer 18

Glasgow-Blatchford score (helps determine whether patient can be managed as OP)
Rockall score (after endoscopy, provides % risk of rebreeding + mortality)

Question 19

What are the elements of the Blatchford score?

Answer 19

Urea
Hb
SBP
HR
Presentation with melena
Presentation with syncope
Hepatic disease
Cardiac failure

Question 20

Which patients may be considered for an early discharge?

Answer 20

Those with Blatchford score of 0

Question 21

Describe resuscitation in an acute upper GI bleed

Answer 21

ABC
Obtain 2x wide bore IV access
Platelet transfusion if actively bleeding/ platelet count <50
FFP if fibrinogen <1 OR
INR/APTT >1.5x normal
PCC to patients on Warfarin + actively bleeding

Question 22

Describe use of endoscopy in an acute upper GI bleed

Answer 22

Endoscopy should be offered immediately after resus if severe bleed
All should have endoscopy within 24h

Question 23

When should PPIs be used in patients with acute upper GI bleeds?

Answer 23

To those with non-variceal bleeds with stigmata of recent haemorrhage seen on endoscopy

NOT to those with suspected non-variceal bleeds prior to endoscopy

Question 24

What management options can be used if there is further non-variceal bleeds?

Answer 24

Repeat endoscopy
Interventional radiology
Surgery

Question 25

Describe management of varicial bleeding

Answer 25

Terlipressin + prophylactic abx given at presentation (before endoscopy)
Oesophageal: Band ligation
Gastric: Inject N-butyl-2-cyanoacrylate

Question 26

What is the second line management if varicial bleeding is not controlled with initial measures?

Answer 26

Transjugular intrahepatic portosysteimc shunts (TIPS)