Clinical aspects of an upper GI bleed

Question 1

How do upper GI bleeds present?

Answer 1

• Melaena
• Haematemesis
• Coffee-ground vomiting

Question 2

What causes an upper GI bleed?

Answer 2

• Bleeding from:
  
  • Stomach
  • Duodenum
  • Oesophagus

Question 3

What are the top 3 causes of upper GI bleeding?

Answer 3

1. Peptic ulcer
2. Oesophagitis
3. Gastritis

Question 4

What are peptic ulcers caused by?

Answer 4

• Acid
• NSAIDs
• H. Pylori

Question 5

Describe the management of an upper GI bleed?

Answer 5

• Resuscitate if required
• Endoscopic risk assessment
• Drug therapy and transfusion

Question 6

What are the different levels of risk of GI bleed and how do you time endoscopy for each of them?

Answer 6

• Low risk
  
  • Outpatient management
• Moderate risk
  
  • Admit and next day endoscopy
• High risk
  
  • Emergency endoscopy

Question 7

How are severe upper GI bleeds identified?

Answer 7

• Age
• Pulse/BP
• Comorbidities

Question 8

Name a endoscopic risk score for upper GI bleeds?

Answer 8

Rockall

Question 9

Name some clinical scoring systems for upper GI bleeds?

Answer 9

• Admission Rockall
• Glasgow Blatchford

Question 10

What is the purpose of the Rockall Scoring systems for upper GI bleeds?

Answer 10

Predict mortality

Question 11

Name some endoscopic therapies for upper GI bleeding?

Answer 11

• Heater probe
• Endoscopic clips
  
  • Thrombin, laser
• Adrenaline injection

Question 12

Describe the use of IV PPIs in upper GI bleeds?

Answer 12

• Given post-endoscopy
• Only for higher risk patients
• Reduce bleeding and mortality

Question 13

What are the next steps if someone taking Aspirin and NSAIDs has an upper GI bleed?

Answer 13

• Stop NSAIDs
• Continue low dose aspirin once haemostasis is achieved

Question 14

What are the next steps if someone taking Copidogrel, Warfarin or DOACs has an upper GI bleed?

Answer 14

• Achieve haemostasis
• Discuss risks with patient and medical team
  
  • Drugs are usually then restarted

Question 15

Describe the use of blood products in upper GI bleeding?

Answer 15

• Give FFP if INR >1.5
• Tranfuse blood when Hb <7
• Tranfuse platelets if bleeding and platelets <50x10⁹
• Give prothrombin complex concentrate if active bleeding on warfarin

Question 16

How are varices treated?

Answer 16

• TIPS
• B-blockers
• Endoscopic banding

Question 17

Why is the incidence of varices increasing?

Answer 17

• Rise in:
  
  • Alcoholism
  • Hep C infections
  • Fatty liver disease

Question 18

What causes varices?

Answer 18

• Increased portal pressure due to:
  
  • Increased portal inflow
  • Increased hepatic resistance

Question 19

How can Acute variceal bleeding be diagnosed?

Answer 19

Endoscopy

Question 20

Describe the resuscitation of Acute variceal bleeding?

Answer 20

• Tranfuse once Hb<7
• Restore circulatory volume

Question 21

Describe the drug therapy for Acute variceal bleeding?

Answer 21

• Early antibiotics and vassopressors
• Endoscopic band ligation

Question 22

Name a vasopressor?

Answer 22

Terlipressin

Question 23

What does TIPS stand for?

Answer 23

Trans-jugular intrahepatic portal shunt

Question 24

What can be done if variceal bleeding cannot be controlled?

Answer 24

• TIPS
  
  • high mortality
• Sengstaken tube

Question 25

What is given for primary prophylaxis of variceal bleeding?

Answer 25

Banding or beta blockers

Question 26

What is the first line for oesophageal variceal bleeding?

Answer 26

Banding

Question 27

What is given for acute gastric variceal bleeding?

Answer 27

Tissue glue injection

Question 28

What is given for prevention of rebleeding of varices?

Answer 28

Beta blocker AND repeated banding

Question 29

Describe the steps for optimal management of upper GI bleeding?

Answer 29

* Resuscitate * Risk assess * Timing of endoscopy * Drug therapy and tranfusion