Gastro Medicine -Acute upper gastrointestinal bleeding

Question 1

NICE published guidelines in 2012 on the management of acute upper gastrointestinal bleeding which is most commonly due to either peptic ulcer disease or oesophageal varices.

Risk assessment

• use the Blatchford score at first assessment, and
• the full Rockall score after endoscopy

Answer 1

Question 2

Use the full Rockall score after endoscopy?

Answer 2

Question 3

Resuscitation?

Answer 3

• ABC, wide-bore intravenous access * 2
• platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
• 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

Question 4

Endoscopy?

Answer 4

• should be offered immediately after resuscitation in patients with a severe bleed
• all patients should have endoscopy within 24 hours

Question 5

Management of non-variceal bleeding?

Answer 5

• NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
• if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Question 6

Management of variceal bleeding?

Answer 6

• 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 7

A 50-year-old man presents to the emergency department with haematemesis which he has never had before. He mentions a 4 week history of intermittent dull pain in the upper left quadrant and, when questioned, he says he thinks he has been losing weight but he has always been fit so doesn’t weigh himself often. Apart from a severely sprained ankle 8 weeks ago, for which he admits he is still taking ibuprofen, he has no medical conditions and is on no regular medication. He is a none smoker and rarely drinks alcohol. What is the most likely cause of the patient’s haematemesis?

Answer 7

• Peptic ulcer is a common cause of haematemesis in patients who have been extensively using NSAIDs as is the case with this patient.
• Peptic ulcers can present with an array of symptoms including haematemesis, abdominal pain, nausea, weight loss and acid reflux.
• Typically the pain improves when the patient eats or drinks.