Gastroenterology - GI Bleeding

Question 1

What is haematemesis?

Answer 1

Fresh blood vomited

Question 2

What is malaena?

Answer 2

Black, tarry, sticky stool

Question 3

What is haematochezia?

Answer 3

Fresh PR bleeding

Question 4

Pathophysiology of peptic ulceration?

Answer 4

Breakdown of the stomach mucosa by:
- steroids
- NSAIDs
- H. pylori

or increased stomach acid production by:
- stress
- alcohol
- caffeine
- smoking

causes the stomach acid to irritate the epithelial lining, causing ulceration.

Question 5

Presentation of peptic ulcers.

Answer 5

• epigastric discomfort / pain
• n+v
• dyspepsia
• haematemesis
• coffee ground vomiting
• malaena
• iron deficiency anaemia

Note gastric ulcers usually have post-prandial agitation, while duodenal ulcers have post-prandial relief.

Question 6

How are peptic ulcers diagnosed?

Answer 6

Endoscopy

Rapid urease test can be performed to check for H. pylori during endoscopy.

Question 7

Peptic ulcer management?

Answer 7

PPI (+2x abx if H. pylori present)

Endoscopy can be used to monitor the ulcer to ensure it heals, and to assess for further ulcers.

Question 8

Complications of peptic ulceration.

Answer 8

• bleeding from splenic artery
• perforation resulting in acute abdomen and peritonitis
• pyloric stenosis (?SBO)

Question 9

From which organs do upper GI bleeds commonly originate?

Answer 9

• oesophagus
• stomach
• duodenum

Question 10

What are the causes of upper GI bleed?

Answer 10

• oesophageal varices
• Mallory-Weiss tear
• ulcers of the stomach or duodenum
• cancers of the stomach or duodenum

Question 11

Presentation of upper GI bleed.

Answer 11

• haematemesis
• coffee ground vomit
• malaena
• haemodynamic instability*

*Younger, fit patients may compensate well until they have lost a lot of blood.

Question 12

What is the Glasgow-Blatchford score?

Answer 12

A scoring system in suspected upper GI bleed, which establishes the risk of having an upper GI bleed based upon:
- drop in Hb
- rise in urea
- hypotension
- tachycardia
- malaena
- syncope

A score > 0 indicates high risk for upper GI bleed.

Question 13

Why does urea rise in upper GI bleeds?

Answer 13

Erythrocytes are broken down by the acid and digestive enzymes, into haem and globin.

Globin is metabolised into amino acids > ammonia > urea within the liver. The urea is then reabsorbed in the GI tract, increasing serum [urea].

Question 14

What is the Rockall score?

Answer 14

Calculates the risk of rebleeding in patients who have had an endoscopy, taking into account:
- age
- tachycardia
- hypotension
- co-morbidities
- cause of bleeding
- endoscopic stigmata of recent haemorrhage

Question 15

Management of upper GI bleed.

Answer 15

ABATED

A - ABCDE approach to immediate resuscitation
B - Bloods
A - Access (2x large bore cannulas)
T - Transfuse
E - Endoscopy (urgent within 24 hrs)
D - drugs (stop anticoagulants and NSAIDs)

Question 16

Which bloods should be sent for in upper GI bleed?

Answer 16

• FBCs (haemoglobin, platelets)
• U&Es (urea)
• INR (coagulation)
• LFTs (liver disease)
• crossmatch 2 units of blood

Question 17

Which products should be transfused in upper GI bleed?

Answer 17

Blood, platelets and clotting factors (fresh frozen plasma) to patients with massive haemorrhage.

Platelets should be given in active bleeding and thrombocytopenia.

Prothrombin complex concentrate can be given to patients taking warfarin that are actively bleeding.

Question 18

If oesophageal varices are the suspected cause of upper GI bleed, what additional management steps should be taken?

Answer 18

• terlipressin
• prophylactic broad spectrum abx