GI Bleeding

Question 1

What is the most common causes of GI bleeding?

Answer 1

DU ulcer
GU ulcer
Varices
Mallory-Weiss tear

Question 2

How would you assess the severity of the haemorrhage?

Answer 2

The 100 rule

Systolic BP < 100mmHg
Pulse > 100
Hb < 100g/l
Age > 60 
Cormorbid disease 
Postural drop in BP

Question 3

How would you treat a patient with GI bleeding?

Answer 3

RESUSCITATE
Airway protection
Oxygen
IV fluids - wide bore cannula

Question 4

What investigation might you do and why?

Answer 4

Endoscopy - identify the cause, therapeutic manoeuvres, assess rick of re-bleeding

Question 5

What is the Rockall risk score for GI bleeding?

Answer 5

A scoring system to assess the severity of bleeding

Question 6

What other scoring system might you do instead of the Rockall risk score?

Answer 6

The blatchford score

Question 7

What might you see that would be suggestive of recent haemorrhage?

Answer 7

Active bleeding/ozzing
Overlying clot
Visible vessel

Question 8

What might be the treatments given for a bleeding peptic ulcer?

Answer 8

Endoscopy treatment (high risk ulcers)
Acid suppression (infusions) - omeprazole
Surgery

H.Pylori eradication - secondary prevention

Question 9

What different endoscopic treatments of peptic ulcers are there?

Answer 9

Injection - adrenaline
Heater probe coagulation
Combinations
Clips
Haemospray - causes mechanical barrier over the bleeding site

Question 10

What would you do if you treated a pt with peptic ulcers with adrenaline injection/heater probe etc and the bleeding didn’t stop?

Answer 10

Take straight to surgery

Question 11

What would you do if the patient after having initial management to stop the bleeding had a re bleed?

Answer 11

Give omeprzole and try again for endoscopic therapy

if didn’t work take to surgery

Question 12

What should you do if you have a patient who has successful peptic ulcer bleeding stop?

Answer 12

Give omeprazole

H.Pyloric eradication as appropriate and course of oral PPI

Question 13

What are the risk factors for Acute Vatical Bleeding?

Answer 13

Portal pressure > 12mmHg
Caricies
presence of red signs
degree of liver failure

Question 14

What do the majority of patients with varices have?

Answer 14

Chronic liver failure

Question 15

What things in a history might suggest varices in a patient?

Answer 15

chronic alcohol excess
chronic viral hepatitis infection
metabolic or autoimmune liver disease
intra-abdominal sepsis/surgery

Question 16

What are the aims of management?

Answer 16

Resusciation
Haemostasis
Prevent complications of bleeding
Prevent deterioration of liver function
Prevent early re-bleeding

Question 17

What should your initial considerations be in a GI bleed?

Answer 17

coagulopathy (FFP/platelets/vitamin K)
CVP monitoring (portal pressure vs CVP)
parenteral vitamins
antibiotics (Goulis et al, 1999, Bernard et al, 1999)
unexpected pathology e.g. perforated D.U.
hypoglycaemia
replace K+, Mg2+ and PO42-
delirium tremens (perhaps later)

Question 18

How can you achieve haemostasis?

Answer 18

Terlipressin (vasopressin analogue)
Endoscopic variceal ligation (banding)
(Sclerotherapy)
Sengstaken-Blakemore balloon
TIPS

Question 19

Describe more about Terlipressin?

Answer 19

Vasopressin prodrug
Predominantly splanchnic vasoconstrictor
Beneficial effect on real perfusion
Superior to vasopressin, somatostatin etc

Question 20

Describe banding?

Answer 20

You just band the varices

Question 21

What is TIPS?

Answer 21

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that may be used to reduce portal hypertension and its complications, especially variceal bleeding. A TIPS procedure may be done by a radiologist, who places a small wire-mesh coil (stent) into a liver vein.