GI Bleeding & Perforation

Question 1

Give some examples of causes of upper GI bleeding.

Answer 1

Oral cavity & nasopharynx

Oesophagus: tumour, Mallory-Weiss tear, varices

Stomach: tumour, ulcers, erosions, Dieulafoy’s lesion (tortuous arteriole), batteries

Duodenum: ulcers, haemobilia (iatrogenic)

Question 2

Give some examples of causes of lower GI bleeding.

Answer 2

Small bowel: tumours, ulceration, IBD, Meckel’s diverticulum

Large bowel: tumours, diverticula, radiation damage, AV malformation/angiodysplasia, IBD, haemorrhoids, varices, vasculitis

Question 3

Outline the management of upper GI bleeding.

Answer 3

• resuscitation & stabilisation
• Hx: alcohol, clotting disorders, malignancy, drugs (warfarin, NSAIDs, steroids)
• OGD +/- endoscopic intervention
• PPI +/- H. pylori eradication
• varices treatment
• surgery

Question 4

What scoring system predicts the likelihood that a patient with an acute upper GI bleed will require intervention?

Answer 4

Glasgow-Blatchford score

• [urea]blood
• Hb
• systolic BP
• tachycardia
• melaena
• syncope
• hepatitc/CVS failure

Question 5

What scoring system selects patients with upper GI bleeding for endoscopic intervention?

Answer 5

Forrest classification

Ia = spurting haemorrhage 
Ib = oozing haemorrhage

IIa = visible vessel 
IIb = adherent clot 
IIc = flat pigmented haematin on ulcer base 

III = lesions without signs of recent haemorrhage or fibrin-covered clean ulcer base

Question 6

What scoring system predicts the likelihood of adverse events following an upper GI bleed?

Answer 6

Rockall score

• age
• hypovolaemic shock (tachycardia, increased capillary refill, tachypnoea, oligouria)
• co-morbidities
• evidence of bleeding
• diagnosis

Question 7

Describe the presentation and investigations in a lower GI bleed.

Answer 7

Minor bleed PR OR massive blood loss (collapse, palpitations, angina, MI)

Ix:
BLOODS:
- FBC
- U&Es
- LFTs
- clotting 
- crossmatch 

IMAGING:
- mesenteric angiogram (CT)

FUNCTIONAL:

• ECG
• sigmoidoscopy/colonoscopy
• mesenteric angiogram

Question 8

Outline the general management of a lower GI bleed.

Answer 8

• resuscitation: 2 large bore cannulae, IV fluids, urinary catheter, O2
• conservative/radiological
• surgical

Question 9

Give some examples of causes of GI perforation.

Answer 9

Upper GI: ulcers, cancer

Small bowel: cancer, foreign bodies, obstruction, trauma

Large bowel: diverticular disease, cancer, obstruction, IBD, iatrogenic, appendicitis

Question 10

Outline the presentation of GI perforation.

Answer 10

• abdominal pain
• generalised peritonitis
• hyperdynamic circulation: tachycardia, pyrexia, flushed
• shock

Question 11

What are the appropriate investigations in GI perforation?

Answer 11

BLOODS:

• FBC
• U&Es
• clotting
• crossmatch
• ABG

IMAGING:

• CXR/AXR: Rigler’s sign (double wall)
• CT: 5-10ml of air detectable

FUNCTIONAL:
- ECG

Question 12

Outline the general management of GI perforation.

Answer 12

• resuscitation: IV fluids, O2, catheter, IV Abx, analgesia
• medical: Abx, bowel rest, TPN, PPI, radiological drainage of abscesses
• surgical: oversew upper GI perforation, resect small bowel/colonic perforation (stoma formation)