GI bleeding

Question 1

what is haematemesis?

what is melaena?

Answer 1

Haematemesis = vomiting of blood

Melaena = production of dark sticky faeces containing partly digested blood, as a result of internal bleeding

Question 2

what are some causes of internal GI bleeding?

Answer 2

1) duodenal ulcer
2) gastric erosion
3) gastric ulcers
4) varices
5) mallory-weirs tear
6) oeosphagitis
+ erosive duodenitis
+ neoplasm
+ stomal ulcer
+ oesophageal ulcer

Question 3

how would you ensure airway protection in an internal GI bleed?

Answer 3

• airway protection
• oxygen
• IV access
• fluid

Question 4

what is the 100 rule?

Answer 4

= poor prognosis group

• systolic BP < 100mmHg
• pule > 100/min
• Hb < 100g/l
• age > 60
• co-morbidites
• postural drop in BP

+ your people compensate then crash hard
+ diabetes have poor autonomic response
+ beta blockers
+ resuscitate = prompt endoscopy

Question 5

why is an oesophago-gastroduodenal endoscopy (OGD) done?

Answer 5

1) identity cause
2) therapeutic manoeuvres
3) assess risk of re- bleeding

Question 6

note the rockall risk scoring system.

Answer 6

note the rockall risk scoring system.

Age
< 60 = 0
60-79 = 1
> 80 =2

Pulse
< 100 = 0
> 100 = 1

SBP
>100 = 0
< 100 = 1

Co-morbidites
none = 0
IHD, CCF = 2
renal/liver failure/malingnacy - 3

Diagnosis
no lesion/MW tear = 0
all others = 1
UGI cancer = 2

Stigmata
none, dark spots = 0
bleeding, clot, visible vessel =2

Question 7

wha are the 2 types of bleeding?

Answer 7

1) bleeding peptic ulcer

2) variceal bleeding

Question 8

what 3 things could be seen in bleeding peptic ulcers?

Answer 8

1) active bleeding/oozing
2) overlying clot
3) visible vessel

Question 9

generally, how would you treat bleeding?

Answer 9

1) endoscopic treatment (high risk ulcers)
2) acid suppression (?infusions)
3) interventional radiology
4) surgery
5) H. pylori eradication = secondary prevention

Question 10

what are 2 potential causes of clot dissolution?

Answer 10

1) acid

2) pepsin

Question 11

what 5 things are involved in treating peptic ulcers?

Answer 11

1) injection = adrenaline
2) heater probe coagulation
3) combinations
4) clips
5) haemo-spray

Question 12

how does haemospray work?

Answer 12

• comes into contact with blood, powder absorbs water, then acts cohesively and adhesively, forming mechanical barrier over bleeding site.

Question 13

what is used for acid suppression?

Answer 13

Proton pump inhibitors

Example = IV omeprazole

Question 14

describe the various routes that could be taken at peptic ulcer endoscopy.

Answer 14

PEPTIC ULCER ENDOSCOPY
= ADRENALINE INJECTED/HEATER PROBE THERMO-COAGULATION/CLIPS
= unable to stop
= surgery

= ADRENALINE INJECTED/HEATER PROBE THERMO-COAGULATION/CLIPS
= bleed stops
= omeprazole 80mg iv
+ 8mg/hr/72hrs ivi
= H. pylori eradicated as appropriate and course of oral PPI

= ADRENALINE INJECTED/HEATER PROBE THERMO-COAGULATION/CLIPS 
= re-bleed after initial haemostats 
= omeprazole 80mg iv + 8mg/72hours/ivi
= further attempt at endoscopic therapy 
= if bleed continues
= surgery

Question 15

what are 4 risk factors for variceal bleeding?

Answer 15

1) portal pressure > 12mmHg
2) varices > 25% oesophageal lumen
3) presence of red signs
4) degree of liver failure (child’s A<b></b>

Question 16

what are 2 complications of variceal bleeding?

Answer 16

= sepsis

= liver failure

Question 17

when would you suspect varicose in a bleeder?

Answer 17

1) known history of cirrhosis with varices
2) chronic alcohol excess
3) chronic viral hepatitis infection
4) metabolic or auto-immune liver disease
5) intra-abdominal sepsis/surgery

+ chronic liver disease

Question 18

what are 5 aims of management?

Answer 18

1) resuscitation
2) haemostasis
3) prevent complications of bleeding
4) prevent deterioration of liver function
5) prevent early re-bleeding

Question 19

what initial considerations should be done?

Answer 19

1) coagulopathy (FFP/platelets/Vit K)
2) CVP monitoring (portal pressure vs CVP)
3) parenteral vitamins
4) antibiotics
5) unexpected pathology e.g. perforated Duodenal ulcers
6) hypoglycaemia
7) replace K+, Mg2+, PO42-
8) delirium tremens

Question 20

what 5 things would allow you to develop haemostats?

Answer 20

1) telipressin (vasopressin analogue)
2) endoscopic variceal ligation (banding)
3) sclerotherapy
4) sengstaken-blakemore balloon
= failure of endoscopy haemostats
= delay until endoscopy
5) TIPS
= known cirrhotic with uncontrollable bleeding gastric varices

Question 21

describe telipressin, a vasopressin prodrug.

Answer 21

= taken as bolus 1-2mg 4hrly

• predominantly splanchnic vasoconstrictor
  + beneficial on renal perfusion
  + superior to vasopressin, somastatin, octreotide

Question 22

describe the treatment process in a variceal bleed.

Answer 22

RESUSCITATION, ANTIBIOTICS, TERLIPRESSIN + EARLY OGD + EVL
= Bleed stops
= propanolol + banding programme

RESUSCITATION, ANTIBIOTICS, TERLIPRESSIN + EARLY OGD + EVL 
= bleed continues
= EVL or S-B tube 
= bleed continues
= TIPSS 

TIPSS

• hepatic function good
• observe

TIPSS

• hepatic function poor
• transplant