Gastro - Upper GI Bleed

Question 1

A person comes in with significant haematemesis. Name the 4 most common causes.

Answer 1

1. Bleeding gastric or duodenal ulcer
2. Oesophageal varices
3. Gastritis, oesophagitis or duodenitis
4. Mallory-Weiss tear (non-transmural oesophageal tear associated with vomiting)

Question 2

A person comes in with significant haematemesis. Suggest uncommon causes for this.

Answer 2

1. oesophageal cancer
2. gastric cancer
3. arteriovenous malformation
4. bleeding diathesis
5. trauma to oesophagus or stomach
6. angiodysplasia in oesophagus or stomach (e.g. Dieulafoy lesion, scleroderma, hereditary haemorrhagic telangiectasia)
7. boerhaave’s syndrome (transmural perforation of the oesophagus associated with vomiting)
8. aorto-enteric fistula

Question 3

which risk assessment tool would you use on a person presenting with haematemesis?

Answer 3

BLATCHFORD SCORE: any pt scoring >0 at risk of intervention/OGD

Parameters:

1. BUN
2. haemoglobin
3. systolic BP
4. other markers
   
   • pulse
   • presentation with melaena
   • presentation with syncope
   • hepatic disease
   • heart failure

Question 4

which investigations would you perform on someone presenting with haematemesis?

Answer 4

Bloods

• FBC: assess Hb trend and need for transfusion
• UandE: esp. BUN
• LFTs: ?liver disease
• clotting (PT, aPTT, INR, fibrinogen): ?need blood products?
• crossmatch: 2-6 units according to rate of active bleeding
• group and save: in case of surgery

Imaging

• OGD: emergency or outpatient according to scenario
• erect CXR: ?pneumoperitoneum, ?Boerhaave’s perforation (L pleural effusion)
• CT chest/abdo: if known aortic graft
• angiogram: if OGD fails to reveal source

Question 5

which scoring system would you use post-endoscopy?

Answer 5

ROCKALL SCORE: predict risk of mortality and re-bleeding

Pre-endoscopy:

• age
• shock (HR and BP)
• co-morbidities (HF, IHD, renal or hepatic failure, disseminated malignancy)

Post-endoscopy:

• stigmata of recent haemorrhage
• diagnosis

Question 6

how would you initially manage a pt with significant UGIB?

Answer 6

1. place 2 wide-bore cannulae and take bloods
2. fluid resuscitation
3. major haemorrhage protocol

Question 7

how would you manage a pt with non-variceal UGIB?

Answer 7

1. Endoscopy treatment should be delivered IF: actively bleeding lesions, non-bleeding visible vessels and ulcers with adherent blood clot.
   Use one of following:
   
   • mechanical method, e.g. clips +/- adrenaline
   • thermal coagulation + adrenaline
   • fibrin/thrombin + adrenaline
2. If re-bleeding after Tx, try interventional radiology, embolisation of artery using foam or coils or surgery if not immediately available.
3. Offer PPI after endoscopy.

Question 8

how would you manage a pt with variceal UGIB?

Answer 8

1. offer TERLIPRESSIN (stop after definitive haemostasis achieved or after 5 days)
2. offer PROPHYLACTIC ANTIBIOTIC THERAPY
3. consider BALLOON TAMPONADE as temporary salvage if uncontrolled haemorrage
4. oesophageal varices:
   
   • band ligation
   • if above fails, try stent insertion or transjugular intrahepatic portosystemic shunts (TIPS)
     gastric varices:
   • endoscopic injection of N-butyl-2-cyanocrylate
   • if above fails, try TIPS