GI Bleeds

Question 1

What are some common causes of upper GI bleeding?

Answer 1

Peptic ulcer disease
Erosive oesophagitis
Esophageal varices
AVM
Mallory weiss tear
Cancer causing bleeding

Question 2

What are some causes of lower GI bleeding?

Answer 2

Diverticulosis
CRC
Hemorrhoids
AVM
Intestinal ischemia

Question 3

What are some signs of upper GI bleeding?

Answer 3

Haematemesis- vomiting of blood

Malena- if it has digested

Question 4

What blood tests should be done for suspected upper GI bleeds?

Answer 4

FBC- initially normal but this declines
U and Es- Urea levels can be sign of location of the bleeding
AST, ALT, Gamma GT, Bilirubin, Albumin
Clotting studies
Group and save- in case of transfusion

Question 5

What approach should you have for the management of upper GI bleeding?

Answer 5

ABCDE- its a medically emergency

Question 6

What puts someone at risk of developing an upper GI bleed?

Answer 6

Chronic NSAID usage
Peptic ulcer disease
H.Pylori infection
Liver disease leading to esophageal varices
Recurrent severe vomiting

Question 7

How are patients with an upper GI bleed assessed?

Answer 7

Blatchford score- scores of 6 or more indicate a need for intervention

Question 8

If someone is bleeding what should be done to resuscitate them?

Answer 8

IV Fluids- Saline or Hartmann’s

Question 9

What methods might be used to resuscitate the patient?

Answer 9

Activate major haemorrhage protocol if indicated
Fluid resus via two large bore cannulas
Blood Products- Red cells, FFP, Frozen Cryoprecipitate if indicated

Question 10

What should patients be done for patients with an unstable upper GI bleed?

Answer 10

Urgents upper GI endoscopy after resus

Question 11

What should be done for patients with a stable upper GI bleed?

Answer 11

Endoscopy within 24 hours

Question 12

What might be done during endoscopy to stop the bleed?

Answer 12

Management depends on whether it is a variceal bleed or not:
Variceal bleeds- clipping, band ligation, TIPS
Non Variceal bleeds- thermal coagulation, adrenaline injections, fibrin or thrombin injections

Question 13

What should be given for patients found to have an upper GI bleed due to varices?

Answer 13

Terlipressin- causing splanchnic vasoconstriction and so reduces blood loss

Question 14

What should be given for fluid resus?

Answer 14

500ml over 15 minutes

Then re-assess and repeat

Question 15

What scoring system can be used to estimate the severity of GI bleeding after endoscopy?

Answer 15

The Rockall Score

Or Haemorrhagic Shock Classifications

Question 16

What is the test to check for H.Pylori infection?

Answer 16

CLO Test - checks for the urease enzyme which is present if there is a H.Pylori infection

Colour change is seen from yellow to red

Question 17

What test can be done to check for H.Pylori?

Answer 17

Carbon-13 Urea breast test
Stool antigen

(depends what is available)

Question 18

What is the treatment for H.Pylori?

Answer 18

PPI + Amoxicillin + Clarithromycin or Metronidazole

If Penicillin allergic- PPI + Clarithromycin + Metronidazole

Question 19

What should be done to check if the eradication therapy was successful?

Answer 19

Urea breath test 8 weeks after eradication therapy

Stop taking the PPI one week before the breath test

Question 20

What blood tests can check for liver disease?

Answer 20

LFTs
Clotting
Platelets- Low platelet count often seen
Albumin

Note- variceal bleeds rarely occur in patients with normal platelet count.

Question 21

What medication should be given to reduce the risk of variceal bleeds?

Answer 21

Propranolol

Question 22

What does a TIPS do?

Answer 22

Reduces portal pressure by creating a stent between the hepatic vein and portal vein thereby bypassing the liver

TIPS stands for Transjugular intrahepatic portosystemic shunt

Question 23

What are mallory weiss tears associated with?

Answer 23

Forceful repeated vomiting often in alcoholics

There are episodes of bleeding and then blood in the vomit

Question 24

What are some causes of lower GI bleeding?

Answer 24

CRC
Haemorrhoids
Diverticular disease
Polyps
Intestinal ischaemia

Question 25

What is a big risk factor for bowel ischaemia?

Answer 25

AF

Question 26

How does ischemic colitis present?

Answer 26

Sudden onset abdominal pain
Blood in the stool
Bowel obstruction/perforation if necrotic tissue
Sepsis if bowel obstruction

Question 27

What investigation should be done for acute bowel ischaemia?

Answer 27

CT Abdomen