Clinical aspects of upper GI bleed

Question 1

What are the presentations of an upper GI bleed?

Answer 1

• Haematemesis
• Coffee ground vomiting
• Melaena

Question 2

What are the top 5 causes of upper GI bleed in the UK?

Answer 2

• Peptic ulcer
• Oesophagitis
• Gastritis
• Duodenitis
• Varices

Question 3

Give a brief overview of upper GI bleeding management

Answer 3

•Resuscitate as required
  - pulse and BP monitoring 
  - IV access for fluids/bloods 
  - lie flat and give oxygen 
•Risk assessment and timing of the endoscopy
  - High risk: emergency endoscopy 
  - moderate risk: admit and next day endoscopy 
  - Low risk: out patient management  
•Drug therapy and transfusion

Question 4

What classifies a severe upper GI bleed

Answer 4

The clinical assessment:
•Pulse and BP
•Age
•Comorbidities (tend to be the cause of death from GI bleed)

Question 5

What are the risk scores for upper GI bleed patients?

Answer 5

•Endoscopic = Rockall
•Clinical:
- admission rockall
- Glasgow Blatchford

Question 6

What does the Rockall score predict?

Answer 6

Mortality

Question 7

What does the Glasgow Blatchford score predict?

Answer 7

Need for intervention or death

Question 8

Which lesions causing an upper GI bleed are endoscopically treated and which are not?

Answer 8

Those treated:
•lesions spurting blood
•Non bleeding visible vessel
•Clot formed over ulcer

Not treated:
•Dot
•clean base

Question 9

What are the endoscopic therapies for the treatment of an upper GI bleed?

Answer 9

• Adrenaline injeciton
• Heater probe (smaller blood vessels only)
• Endoscopic clips
• Hemostatic powders (for more diffuse bleeds or those that you cannot easily control)
• (thrombin, laser)

Question 10

What is the drug therapy for upper GI bleeds?

Answer 10

PPIs reduce rebleeding and mortality if given post-endoscopy to high risk patients who required endoscopic therapy

Question 11

What should you do in patients with an upper GI bleed on anti platelets and anticoagulants?

Answer 11

• Continue low dose aspirin once haemostats achieved (and add PPI)
• Stop NSAIDs
• For Clopidogrel, warfarin and DOACs, once haemostasis is achieved, assess the risk vs benefit but generally aim to restart

Question 12

Explain the use of blood products in upper GI bleeding

Answer 12

• Transfuse blood once Hb is <7-8g/dL
• Transfuse platelets if actively bleeding and platelet count <50x109/L
• FFP if INR>1.5
• Vitamin K and prothrombin complex concentrate if on warfarin and actively bleeding

Question 13

Why has there been a rise of upper GI bleeding due to varices?

Answer 13

Due to the rise of:
•Alcohol
•Hepatitis C
•non alcoholic fatty liver disease

Question 14

Describe the formation of varices

Answer 14

Cirrhosis accounts for most cases of portages; hypertension:
•In cirrhosis there is increased hepatic resistance: mechanically due to architecture changes, fibrosis and vascular occlusion and dynamically due to endothelial dysfunction and increased vascular tone
•There is increased portal inflow, splanchnic vasodilation
•Angiogenesis -> portal systemic collaterals

Question 15

Describe the treatment of acute variceal bleeding

Answer 15

• Resuscitation: restore circulating volume, transfuse once Hb <7g/dL, consider airway protection
• Diagnose via endoscopy
• Give antibiotics early due to high risk of sepsis, vasopressors (terlipressin), endoscopic band legation, TIPS (trans-jugular intrahepatic stunt shunt - rescue procedure)

Question 16

What is a Sengstaken tube?

Answer 16

Used in an emergency setting - balloon inflated inside the upper GI tract to stop bleeding until you can treat it

Question 17

What is the primary prophylaxis of variceal bleeding?

Answer 17

Beta blockers or band ligation

Question 18

How do you prevent rebleeding of varices?

Answer 18

Beta blocker and repeated band ligation