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AIP: Gastrointestinal bleed > Approach to upper GI bleed > Flashcards

Approach to upper GI bleed Flashcards

1
Q

What are the 2 scoring systems that can be used in upper gastrointestinal haemorrhage?

A
  1. Blatchford score - pre-endoscopy for deciding upon timing of procedure
  2. Rockall score - predicts mortality, can be done pre- and post-endoscopy
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2
Q

Which scoring system for upper GI bleed is favoured by NICE and why?

A

Blatchford score (aka Glasgow-Blatchford) preferred pre-endoscopy for deciding upon timing of the procedure/ predict need for intervention to treat bleeding

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3
Q

What is a low Blatchford score associated with?

A

low score, 2 or less, associated with a very low risk of adverse outcome

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4
Q

What is the commonest cause of upper GI haemorrhage?

A

peptic ulcer secondary to either NSAIDs or Helicobacter pylori

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5
Q

What are the 8 commonest causes of upper GI haemorrhage?

A
  1. Oesophagitis
  2. Peptic ulcer (NSAIDs/H. pylori)
  3. Gastric erosions (NSAIDs/alcohol)
  4. Varices (liver disease/ portal vein thrombosis)
  5. Mallory-Weiss tear
  6. Vascular malformations
  7. Cancer of stomach or oesophagus
  8. Aorto-duodenal fistula
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6
Q

What are 2 appearances of haematemesis and what does the difference indicate?

A
  1. Red with clots - when bleeding rapid and profuse
  2. Black (‘coffee grounds’) when less severe
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7
Q

What is responsible for the characteristic colour and smell of melaena in upper GI bleed?

A

action of digestive enzymes and bacteria on haeoglobin

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8
Q

What approach to management of upper GI haemorrhage should be taken?

A

A to E

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9
Q

What are the steps to taken in the C part of A to E in upper GI haemorrhage?

A
  • Assess heart rate, blood pressure and may indicate hypotension secondary to hypovolaemia
  • Monitor urine output with insertion of a catheter
  • Immediately obtain IV access via 2 wide bore cannulae
  • Take blood tests
    • FBC - may indicate anaemia if chronic blood loss
    • LFTs
    • U+Es
    • Clotting, including prothrombin time
    • Cross match: at least 2 units of blood should be cross-matched if significant bleed suspected
    • Group and save
  • Give IV fluids e.g. 500ml Hartmann’s over 15 min
  • May need to give blood products: cross match and activation of major haemorrhage protocol may be necessary
  • Give terlipressin
  • Give antibiotics (usually quinolones)
  • Make nil by mouth for endoscopy
  • Stop any blood-thinning medication
  • Call gastroenterology to arrange for endoscopy
  • Examination to assess for signs of liver disease and examine abdomen - may be pain
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10
Q

What are 3 types of drugs which may need to be given in patients with upper GI haemorrhage and why?

A
  1. IV terlipressin - if varices
  2. Antibiotics - quinolones, if chronic liver disease suspected
  3. IV PPI - may be initiated
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11
Q

What must be done as part of a patient’s preparation for endoscopy in upper GI bleeding?

A

make patient nil by mouth

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12
Q

When should blood products usually be given in an upper GI haemorrhage?

A

blood transfusion if Hb <7

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13
Q

What blood products should be given in upper GI haemorrhage if indicated?

A

packed red blood cells, with or without platelets and fresh frozen plasma (every 4th unit of blood)

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14
Q

What is the advice regarding giving blood transfusion in normal haemoglobin?

A

overtransfusion can increase mortality so should not be given

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15
Q

What is the recommdnation for endoscopy based upon the Rockall score?

A

if score >0 recommended to have inpatient OGD, but those scoring 0 can have urgent outpatient OGD

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16
Q

What are 5 factors taken into account by the Rockall score?

A
  1. Age (years)
  2. Systolic blood pressure/ pulse rate
  3. Comorbidities
  4. Post-endoscopy diagnosis
  5. Signs at endoscopy
17
Q

What are the parameters considered by the Blatchford score?

A
  • Urea
  • Haemoglobin (different for men and women)
  • Systolic blood pressure
  • Other paremeters:
    • Tachycardia
    • Clincally observed malaena
    • Syncope
    • Liver disease
    • Heart failure
18
Q

When should oxygen be given in upper GI haemorrhage?

A

all patients in shock

19
Q

What are 2 causes of an aorto-enteric fistula (e.g. aorto-duodenal)?

A
  1. previous abdominal aortic aneurysm
  2. aortic graft
20
Q

What are 4 factors that could make a patient with upper GI bleed more difficult to manage?

A
  1. Risk of fluid overload with aggressive resuscitation e.g. renal disease
  2. Anticoagulation
  3. Liver disease
  4. Thrombocytopenia
21
Q

Within what time frame should endoscopy be performed for upper GI bleed?

A

within 24 hours

22
Q

What treatment specific for varices should be performed during endoscopy? 4 options

A
  1. Band ligation
  2. Balloon tamponade is alternative option: Sengaksten-Blakemore tube (or Minnesota tube)
  3. Sclerotherapy
  4. TIPSS: transjugular intrahepatic portosystemic shunt
23
Q

How quickly should endoscopy be performed for upper GI bleed in unstable patients?

A

immediately after resuscitation or in tandem with it

24
Q

Where should endoscopy be performed in unstable patients?

A

may be safer to perform in theatre with an anaesthetist present as endoscopy department could be dangerous for unstable patients

25
Q

What type of blood will patients awaiting cross matched blood receive?

A

O negative blood

26
Q

How many units of cross-matched blood should be performed if a significant bleed is suspected?

A

at least 2 units

27
Q

What are 3 ways that patients with upper gastrointestinal bleeding present?

A
  1. Haematemesis and/or melaena
  2. Epigastric discomfort
  3. Sudden collapse
28
Q

Wha tis the most common cause of major haemorrhage?

A

posteriorly sited duodenal ulcer

29
Q

What type of endoscopic treatment is used for other causes of GI bleeding (other than varices)? 4 variants

A

Dual therapy: Injection of adrenaline + thermal or mechanical treatment:

  • heater probe
  • endoscopic clips
  • biologically inert haemostatic mineral powder (TC325, haemospray)
  • IV PPI therapy
30
Q

When is surgery indicated following endoscopy for upper GI bleeding? 3 situations

A
  1. when endoscopic haemostasis fails to stop active bleeding
  2. if rebleeding occurs on one occasion in an elderly or frail patient
  3. If rebleeding occurs twice in younger, fitter patient
31
Q

What does the choice of surgery following endoscopy for upper GI haemorrhage depend upon?

A

site and diagnosis of bleeding lesion

32
Q

What is an alternative to surgical management of upper GI haemorrhage in frail patients?

A

angiographic embolisation

33
Q

What surgical option is available for duodenal ulcers?

A

under-running with or without pyloroplasty

34
Q

What surgical option is available for gastric ulcers?

A

under-running, and biopsy to exclude carcinoma

35
Q

What is meant by under-running surgery?

A

2-3 stitches passed deep into the ucler and sutures tied tight to stop the bleeding

36
Q

What is are alterative surgical approaches to managing peptic ulcers other than underrunning?

A

local excision or partial gastrectomy

AIP: Gastrointestinal bleed (11 decks)

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