Gastrointestinal bleeding

Question 1

An upper GI bleed referes to bleeding from which locations?

Answer 1

Oesophagus, stomach or proximal duodenum

Proximal to ligament of treitz

Question 2

List the 3 key symptoms of an upper GI bleed

Answer 2

1. Haematemesis
2. Melaena
3. Haematochezia

Question 3

List 4 oesophageal causes of a UGIB

Answer 3

1. Varices
2. Neoplasm
3. Oesophagitis
4. Ulcer
5. Mallory Weis tear

Question 4

List 4 gastric causes of a UGIB

Answer 4

1. Gastric Ulcer
2. Neoplasm
3. Gastritis
4. Varices
5. Dieulafoy’s lesions (large tortuous arteriole)
6. Angiodysplasia

Question 5

List 4 duodenal causes of a UGIB

Answer 5

1. Duodenal ulcer
2. Neoplasm
3. Duodenitis
4. Vascular malformations
5. Aortoenteric fistulae

Question 6

Which scoring system is used to predict the need for admission and timing of endoscopic intervention

Answer 6

Glasgow-Blatchford Score

Question 7

Which scoring system is used to predict risk of re-bleeding and mortality

Answer 7

Rockall Score

Can be calculated pre and post endoscopy

Question 8

What score should be used at 1st assessment to risk stratify

Answer 8

Blatchford

Question 9

What is the Initial management of a Non-variceal bleed

Answer 9

1. ABCDE
2. Assess degree of shock

Question 10

Management of a Non-variceal bleed?

Answer 10

1. Fluid resuscitation
2. Blood transfusion
3. Vit K or Octaplex
4. PPI, erythromycin, Tranexamic acid
5. Endoscopy

Question 11

Within what time frame is an endoscopy reccomended for UGIB?

Why?

Answer 11

Early endoscopy (within 24hrs)

For prompt diagnosis, risk stratification and haemostasis therapy

Question 12

Endoscopic therapies for UGIB?

Answer 12

Aims to achieved Haemostasis by:

1. Adrenaline injection + 2nd modality
2. Thermal coagulation
3. Mechanical–endoclips
4. Hemospray
5. (Glue/thrombin for varices)

Question 13

What is the Forrest Classification?

Answer 13

ASK RISH

Question 14

What is the only definitive way to treat oesophageal varicies?

Answer 14

TIPS - Transjugular intrahepatic portosystemic shunt

Question 15

In what condition is Variceal bleeds most common?

Answer 15

Cirrhosis (50% of patients)

• 30-40% in compensated disease
• 85% in decompensated

Answer 16

Question 17

Initial management of a Variceal bleed?

Answer 17

1. ABCDE
2. Anaesthetist – consider intubation
3. DOCC / ITU
4. Gastro SpR/Cons on call (out-of hours)

Question 18

Management of a variceal bleed?

(Hint: VARICEAL B)

Answer 18

1. Vasoconstrictor therapy
2. Antibiotics
3. Resuscitation
4. ICU level care
5. Endoscopy
6. ALternative therapies
7. Beta blockade

Question 19

What is the purpose of Vasoconstrictor therapy in management of a VB?

List an example of a medication used

Answer 19

Reduce splanchnic blood flow

eg. Terlipressin, Octreotide

Question 20

Why is it important to administer antibiotics in a VB?

List an example

Answer 20

Bacterial translocation occurs in 2/3 of cases → prophylactic antibiotics significantly reduces mortality

Broad spectrum: Tazocin

Answer 21

Question 22

How soon should an endoscopy be performed following admission of a VB

What endoscopic therapies may aid treatment?

Answer 22

Urgent ASAP after resus! (Intubation often needed)

Therapy

• Variceal band ligation
• Tissue glue cyanoacrylate – gastric varix (we use thrombin)

Question 23

If an endoscopy cannot be performed in a VB, list 2 alternative / rescue therapies

CHECK THIS

Answer 23

1. TIPS (Transjugular intrahepatic portosystemic shunt) → ↓ portal pressure and complications related to portal HTN
2. Sengstaken-Blakemore Tube

Question 24

What is the purpose of Beta blockade in the management of VB?

List an example of a medication used

Answer 24

Reduces risk of recurrent VB

• ↓ splanchnic vasoconstriction
• ↓ CO

Non-selective β-blocker eg. propanolol or carvedilol

Question 25

Post endoscopic management of a non-variceal blead?

Answer 25

1. For low risk ulcers – fed promptly, start oral PPI 2. Forrest classification and risk of re-bleeding 3. If endoscopic therapy – 72 hour PPI infusion 4. If DU – give empirical HP eradication therapy 5. Discharge on PPI (when Hb \>8) and advise against NSAID use

Question 26

Post endoscopic management of a variceal blead?

Answer 26

1. Continue antibiotics 5/7 2. Wean terlipressin early after successful banding 3. Beta blockade (secondary prophylaxis) in combo with 4. Variceal banding programme - repeat OGD at 2-4wks until eradication achieved

Answer 27

Question 28

Management in case of re-bleeds?

Answer 28

Repeat OGD +/- therapeutics

Question 29

Management If bleeding is uncontrolled?

Answer 29

1. Interventional radiology – CT angiogram +/- embolisation vs. TIPSS 2. Surgeons * Under running with or without pyloro-plasty * Local excision or partial gastrectomy

Question 30

A lower GI bleed referes to bleeding from which locations?

Answer 30

colon and rectum

Question 31

Is a patient with **severe** haematochezia more likley to be an UGIB or LGIB

Answer 31

UGIB - 15% of UGIB present as LGIB

Question 32

List 4 painLESS causes of a LGIB, highlight the most common

Answer 32

1. **Diverticular\*** 2. Aortoenteric fistula\* 3. Malignancy 4. Angiodysplasia–Heyde’s syndrome 5. Haemorrhoidal 6. Post-polypectomy

Question 33

List 4 painFULL causes of a LGIB

Answer 33

1. Colitis (UC, Crohns, infectious) 2. Ischaemic colitis 3. Massive UGIB\*

Question 34

Initial management of a LGIB

Answer 34

1. ABCDE 2. Stabilise and resuscitate (fluids/blood products) These are usually self-limiting

Question 35

List 4 investigations for a LGIB

Answer 35

1. OGD 2. CT angiogram 3. Flexible sigmoidoscopy vs colonoscopy

Question 36

List 3 Therpies for a LGIB that is not self-limiting

Answer 36

1. Submucosal injections of adrenaline 2. Clip / heat 3. APC Performed during a Flexible sigmoidoscopy or colonoscopy

Question 37

Under what circumstances would a LGIB require surgery?

Answer 37

Massive haemorrhage + haemodynamic instability → surgery