tbl 2: upper GI bleeding (non variceal)

Question 1

Upper GI tract bleeding (UBGIT) – haemorrhage originating from the oesophagus to the ___________, at the duodenojejunal flexure
o Divided into variceal and non-variceal in
view of different management and prognosis
o Non-variceal – in the absence of oesophageal, gastric or _________ varices

Answer 1

ligament of Treitz; duodenal

Question 2

Lower GI tract bleeding (LBGIT) – historically defined as bleeding that originates from a site distal to the ligament of Treitz
o Recently defined as distal to ______________

Answer 2

ileocecal valve

Question 3

Obscure GI Bleeding: Overt/ Occult bleeding of unknown origin that persists of recurs after an initial negative ______________

Answer 3

OGD & colonoscopy

Question 4

Occult: causes of _____ occult positive and /or unexplained ________

Answer 4

faecal; iron blood deficiency anaemia

Question 5

overt: visible, bleeding in _________

Answer 5

emesis/ stool

Question 6

Clinical features
Hematemesis (vomiting of fresh blood)
- Usually indicates _________, moderate to severe bleeding
- _________ presentation

Coffeeground emesis
- usually indicates ______, lower rate of bleeding (blood reacts with _________)

Melena ( black, tarry and foul smelling stool)
- Caused by degradation of ________ by bacteria in the colon (blood has remained in GI for several hours)
- Usually UGIT source , but can be R colonic bleed with _____
- The further the bleeding site from the rectum, the more likely melena will occur
- However dark stools can result from : iron, ________, charcoal, _________ and licorice
– as little as 50-100ml of blood enters the GI tract, can originate from esophagus, stomach, small intestine or proximal colon

Answer 6

UBGIT; Variceal

UBGIT; hydrochloric acid in the stomach

hemoglobin; slow motility

bismuth; spinach

Question 7

Clinical features

Hematochezia
- Bright red blood - Usually _________; can be brisk proximal source
- _______stools – Usually R colon;
- Can be from massive Upper GI bleed (blood does not remain in colon to turn to melena) -> however will present with ____________
- Up to 15% of patients with presumed LGIB ultimately found to have UGI source
- Suspect if: Hematochezia with hemodynamic instability (esp. in at-risk populations), __________ (LR 7.5 with ratio >30:1), positive NG aspirate
Red blood with clots per-rectum unlikely UGI

Others

• Duration/associated symptoms eg. Abdominal pain, dysphagia, loss of weight
• Symptoms of anemia eg. Fatigue/giddiness/_______/chest pain

Answer 7

L colon; Maroon; hemodynamic instability

elevated BUN:Cr ratio ; exertional dyspnoea

Question 8

Medications to ask for history taking

• anti platelet/anticoagulants/novel anticoagulants/ NSAIDs
• _______ intake
• herbs/supplement/traditional medicine
• changes in medication

Answer 8

alcohol

Question 9

UBGIT and past medical history – potential aetiologies suggested by a patient’s past medical history
- Chronic liver disease – ____________ is always a differential when a patient presents with GI tract bleeding with chronic liver disease
- Prior GI bleeding events, history of peptic ulcer disease
- Post procedure
o Endoscopic retrograde ________ (ERCP) – haemobilia (bleeding into the biliary tree)
o Recent vascular surgery – __________ (a connection between the aorta and the intestines, stomach, or oesophagus)
o Post endoscopic ultrasound (EUS) or endoscopic submucosal dissection (ESD) interventions
- Renal failure – _________ or angiodysplasia (small vascular malformation)
- Pancreatitis (especially – hemosuccus pancreaticus (bleeding from the pancreatic duct into the gastrointestinal tract via the _________-)
- Elderly patient with known aortic stenosis – Heyde syndrome
o Triad of aortic stenosis, an acquired coagulopathy and anaemia due to bleeding from ____________

Answer 9

variceal bleeding

cholangiopancreatography;

aortoenteric fistula

Gastric antral vascular ectasia (GAVE);

ampulla of Vater;

intestinal angiodysplasia

Question 10

Causes and differential diagnosis – common causes of UBGIT
= \_\_\_\_\_\_\_ 31 to 67%
= \_\_\_\_\_\_\_\_\_\_\_ 7 to 31%
= \_\_\_\_\_\_\_\_\_\_ 4 to 20%
= Erosive oesophagitis 3 to 12%
= Mallory-Weiss tear 4 to 8%
= Tumours 2 to 8%
= Aortoenteric fistulas, arteriovenous malfunctions or Dieulafoy’s 2 to 8%

Answer 10

Peptic ulcer;
Gastritis or duodenitis;
Variceal bleeding

Question 11

Other causes
o Oesophageal ulcer – in the right subset of patients such as those at risk of ______
o Cameron ulcer – patients with _____
§ Linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm
o Inflammatory polyps
o Hemosuccus pancreaticus – bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater
§ Predominantly occurs in the settings of chronic pancreatitis, aneurysms of __________, and pancreatic tumour
§ A triad of epigastric pain, gastrointestinal
bleeding and ____________

Post-procedure or intervention
o Polypectomy
o Endoscopic submucosal dissection (ESD)
o Endoscopic retrograde cholangiopancreatography (ERCP)
o Endoscopic ultrasound (EUS) guided interventions
- There is a need to differentiate between haemoptysis and _____________

Answer 11

GERD; hiatus hernia

peripancreatic vessels; hyperamylasaemia

epistaxis with regurgitation

Question 12

Initial assessment and resuscitation
- Physical examination –
o Vital signs monitoring or ___________ assessment including blood pressure (including postural changes), pulse, oxygenation, urine output
o Visible signs of bleeding
o Cardiovascular and abdominal examination
o ________ examination

• Resuscitation –
  o Assess ABC, determine disposition of patient – if assessment by intensive care team or high dependency team required
  § Consider intubation if there is _________ (from large volume haematemesis) or altered mental/respiratory status or with severe neuromuscular disorders
  o Monitoring of vital signs , urine output
  o Consider supplemental oxygen
• Classification of hypovolemic shock (ATLS)
  o 15% blood loss is associated with drop in__________ or with increase in HR > 20bpm on changing posture
• Beware of effects of medications such as –
  o __________ masking reflex tachycardia
  o __________ exaggerating hypotension

Answer 12

ABC (airway, breathing, circulation); Digital rectal

airway compromise;

BP> 20mmhg, Beta blockade, Vasodilators

Question 13

Investigations
o Blood tests – FBC , coagulation profile (PT/PTT+INR), GXM, renal panel (looking at _________)
o Liver function test (LFT), lactate and _____________ (if patient show signs of respiratory distress or altered mental status)
o ECG and Troponin I if indicated
o Imaging – erect CXR looking for free air under diaphragm, and abdomen XR
o Endoscopy – both diagnostic and therapeutic
- Patient should be kept ____________ and timing of last meal known to plan for next endoscopy
- Nasogastric tube insertion for diagnosis, prognosis, therapeutic or visualisation is usually not required
- Ensure at least 2 large bore IV access (16G) and consider __________ if patient is admitted to HD or ICU
- Medication review

Answer 13

creatinine and urea;

arterial blood gas

nil by mouth (NBM)

central venous catheterisation

Question 14

Pre-endoscopy – risk stratification, optimisation and timing
1. Risk stratification – ____________ - Based upon the blood urea nitrogen, haemoglobin, systolic blood pressure, pulse, and the presence of melena, syncope, Hepatic disease, and/or cardiac
failure.
- Main clinical utility – identifying patients who are at low risk/requirement for hospital based intervention
o Patient with _____could be safely discharged from the emergency department for outpatient management
o Seldom used in local setting (Singapore)

Answer 14

Glasgow-Blatchford score; GBS ≤1

Question 15

Important role of resuscitation in optimisation
o Early intensive hemodynamic resuscitation had been shown to lower mortality in acute bleeding patients by -
§ Correcting ______________
§ Restoring _____________
§ Preventing multi-organ failure

• Crystalloids are generally preferred over colloids – there are concerns for colloids such as _________, coagulopathy, and anaphylaxis risk
• Blood transfusion – Hb may remain unchanged with acute bleeding (as a patient loses both blood cells and plasma)
  o However, need to reassess Hb within a few hours (as interstitial fluid moves into vascular space)
  o A restrictive transfusion strategy is encouraged – transfusion only given at Hb < 7 g/dL, with a post-transfusion target of ________, not for patients with
  severe ongoing bleed with ____________ and those with acute myocardial infarction
• Transfusion studies for acute upper GI bleeding (NEJM, 2013)
  o Efficacy and safety of restrictive and liberal transfusion strategies were compared
  o n = 921, restrictive group (461) kept Hb levels at 7 to 9 but liberal group (460) kept Hb levels at 9 to 11
  o Restrictive group had lower 45-day mortality, re-bleeding rates, length of stay and cardiac complications
  § However, cirrhotic patients are included in this trial

Answer 15

intravascular hypovolemia; adequate tissue perfusion

kidney injury

7 to 9 g/dL; hemodynamic compromise;

thrombotic risk

Question 16

Antiplatelets and anticoagulants in optimisation
o Anti-platelets and anti-coagulants should be withheld in patients with UGIB whenever possible – __________ must be weighed against risk of continued bleeding
o The decision to discontinue medication or administer reversal agents needs to be individualised

Straightforward case

• If a patient is on aspirin for stable ischemic heart disease with severe UGIB – stop aspirin, endoscopic evaluation, therapy and restart aspirin once _______ is secured
• Complex case Consult provider (e.g. cardiology, neurology) who prescribed the antiplatelet/anticoagulant e.g. dual antiplatelet for recent NSTEMI with coronary bare metal stent placement with UGIB

Reversible agents:

• Wafarin = _________
• Dabigatran (direct thrombin inhibitor): __________
• FXa inhibitors e.g. rivaroxaban, apixaban: _________

Answer 16

haemostasis

Vitamin K; Idaraiczumab, Andexanet alla

Question 17

Pre-endoscopy:

Correct coagulopathy/platelets
o ___________ if platelet count <50 x 109/L and actively bleeding
o Give ____________ if prothrombin time (or international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal and actively bleeding
o ____________ if a patient’s fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma

• Prokinetic agents – used to improve endoscopic view, increasing the chances of successful haemostasis
  o IV ____________ (250 mg) is given 30 to 120 minutes before endoscopy to promote gastric emptying, clearing blood clots in stomach to improve endoscopic visualisation
  o Alternatively, IV ___________ is given if there is contraindication to erythromycin (e.g. prolonged QTc) – but not been shown to consistently improve clinical outcome
• Pharmacotherapy – acid suppression therapy by ______________has been the drug of choice for acid reduction
  o PPIs increase gastric pH to >6.0 – optimises platelet function, inhibits __________ and reduces peptic activity, increasing clot stabilization over bleeding ulcers
  o Usually, IV PPI is initiated while waiting for OGD
  § e.g. IV esomeprazole 80mg bolus followed by 8mg/hr infusion or bolus followed by 40mg twice daily
  o Significantly decreases the incidence of high risk stigmata of haemorrhage and the need for therapy at the time of index OGD – but has no effect on patient outcomes, including rebleeding, need for surgery, or mortality
  o Compared to PPIs, intravenous H2RAs are ineffective in maintaining a sustained high gastric pH – tolerance develops within 12 hours of infusion

Answer 17

Platelet transfusion; fresh frozen plasma; Cryoprecipitate

erythromycin; metoclopramide

proton pump inhibitors (PPIs) ;

fibrinolysis

Question 18

Timing of endoscopy – urgent endoscopy should be within ____________ after adequate haemodynamic resuscitation
- Endoscopy after less than 6 hours seem unnecessary (from studies)
- Very early (<12 hours) upper GI endoscopy may be considered in patients with –
o Persistent ____________ despite ongoing adequate resuscitation
o In-hospital bloody emesis or nasogastric aspiration
o Contraindication to the interruption of anticoagulation

Answer 18

12 to 24 hours; hemodynamic instability

Question 19

Definitive treatment by eendoscopy via different types of haemostasis modalities

Thermal

• Contact: heater probe
• Non contact: ________

Injection

• Diluted epinephrine, 1:10000 or 1: 20000
• tissue adesives: cyanoacrylate glues or ______
• Solerosants eg. ethanol (more for variceal bleeding)
• primary mechanism of action is ___________ resulting from a volume effect.

Mechanical

• through scope clip
• band litigation
• over the scope clip (OSTC)

Haemostatic powder spray
- Proprietary mineral preparations – sprayed onto a bleeding area through a cannula inserted through the channel of an endoscope, provoking rapid haemostasis - Acts both as a __________ upon contact with moisture and as a __________ by concentrating clotting factors at the site of application

Answer 19

argon plasma coagulation;
local tamponade;
thrombin;
physical barrier; powerful procoagulant

Question 20

Ulcer management
- Ulcers is the most common presenting cause of UBGIT
- _________should be done for endoscopy for peptic ulcers – provides prognostic information in the need
for endoscopic therapeutic intervention and the risk of rebleeding and death
- Ulcer bleeding accounts for 50% of UBGIT
o In which 75 to 80% of cases hemorrhage from ulcers stop spontaneously
- Forrest classification is used to characterize the ulcer and help to determine if further endoscopic therapy is required
o Class ______ – no endoscopic haemostasis required
o Ia, Ib, IIa, IIb – consider removing the clot to assess the ulcer
§ High-risk stigmata – endoscopic haemostasis
§ Low-risk stigmata – high-dose ___________
- ____________should not be used alone – if used, should be combined with a second modality

• Elucidate cause of ulcer and treat if necessary
  o NSAIDS taken – stop medication
  o Immunosuppressed – treat infections e.g. CMV
  o Helicobacter pylori therapy – empirical treatment is not advocated but need to worry about false negative test in acute GI bleeding

Answer 20

Forrest classification;

IIc or III;

IV PPI management

Epinephrine therapy

Question 21

Definitive management
- Management of persistent or recurrent bleeding
o Endoscopic therapy should be repeated once when ___________ after initial endoscopic therapy unless major contraindication
o Addition of __________ or OTSC can be considered if refractory bleeding noted post standard medical and endoscopic therapy

• If repeat endoscopic therapy fails, then consider –
  o _______________ – embolisation with tissue adhesives/coils/absorbable gelatin sponge (but potential complications of embolisation such as ischaemia, perforations or renal impairment)
  o Surgery – reserved for situations in which angiographic therapy is unavailable, delayed, or unsuccessful.
  § Oversewing of ulcer, selective vagotomy, vagotomy and pyloroplasty or gastric resection
  o Prophylactic trans-arterial embolization of high risk ulcers after endoscopic therapy is not recommended as it did not significantly reduce bleeding

Answer 21

bleeding recurs; haemostatic spray powder

Angiographic therapy

Question 22

Post-endoscopy
- ACG 2012 and ESGE 2015 suggests intermittent IV PPI therapy (at least twice daily) for 72 hours post endoscopy if endoscopic haemostasis was performed and for _________________
- If the patient’s condition permits, ____________ may also be an option in those able to tolerate oral medications
o However a meta-analysis of 13 studies found that a bolus followed by intermittent doses of intravenous or oral PPIs was non-inferior to continuous infusion although most individual studies were relatively small and hence guidelines still recommend as above
- High risk stigmata (active bleeding, visible vessels, clots) should generally be
hospitalized for ________ assuming no re-bleeding and no other reason for

Answer 22

untreated adherent clot; high dose oral PPI; 3 days

Question 23

Post-endoscopy
- ACG 2012 and ESGE 2015 suggests intermittent IV PPI therapy (at least twice daily) for 72 hours post endoscopy if endoscopic haemostasis was performed and for _________________
- If the patient’s condition permits, ____________ may also be an option in those able to tolerate oral medications
o However a meta-analysis of 13 studies found that a bolus followed by intermittent doses of intravenous or oral PPIs was non-inferior to continuous infusion although most individual studies were relatively small and hence guidelines still recommend as above
- High risk stigmata (active bleeding, visible vessels, clots) should generally be hospitalized for ________ assuming no re-bleeding and no other reason for hospitalization – may be fed clear liquids soon after endoscopy (clear liquids allow sedation or anaesthesia to be administered within 2 hours after last ingestion)
- Routine 2nd look endoscopy performed 24 hours post initial OGD is not required unless patient has ________
- Medical management with PPI therapy for ______________ is usually recommended after haemostasis is secured

Answer 23

untreated adherent clot; high dose oral PPI; 3 days

recurrent bleeding; another 6 to 8 weeks

Question 24

Reintroduction of antithrombotic/anticoagulant medications
- Mortality after presentation with a bleed is more often caused by underlying comorbidities, particularly cardiovascular disease, rather than the bleed itself
- Timing of reintroduction of such medication depends on – thromboembolic risk, indication of medications – primary vs secondary bleeding risk and adequacy of haemostasis
- A multidisciplinary discussion between specialists should weigh the risks and benefits of restarting such medications
- ESGE guidelines – when to restart antithrombotic looking at the risk of bleeding from ulcers and indication of antithrombotics
o When used for secondary prevention, aspirin should be continued or reintroduced soon (within ___________) after haemostasis is achieved
o Dual antiplatelet therapy (DAPT)*– may confer 3-fold risk of UBGIT over single antiplatelet therapy (SAPT)
§ For patient on DAPT, __________ should be continued and early cardiology consult should be arranged regarding the resumption of second antiplatelet
o In aspirin-related PUD bleeding, resumption of aspirin with concurrent PPI is superior to clopidogrel alone for prevention of recurrent BGIT (ASGE 2016)

Answer 24

3 days

low dose aspirin

Question 25

• DAPT involves the use of both aspirin and another P2Y12 inhibitor such as __________
• For patients on DAPT, withholding both antiplatelet drugs because of coronary stent thrombosis can be as short as 7 days with both drugs withheld as compared with 122 days with only clopidogrel withheld
• For those with higher risk of thrombosis such as those with drug-eluting coronary stents, clopidogrel should not be discontinued for more than 5 days
• Warfarin – robust data on the optimal timing on reintroduction of warfarin has been limited
  o Recent guidelines suggest restarting warfarin from “as soon as haemostasis is established” ____________ after the bleeding event
  o Early resumption within a week using ___________ (unfractionated or low molecular weight heparin) may be considered for those with high thrombotic risk

Data on Non-Vitamin K antagonist oral anticoagulant (NOAC) reintroduction has been limited – depends on the balance of risk between rebleeding and thromboembolic events
§ Caution in early resumption of NOAC is required – rapid onset of action and lack of accessible reversal agents

Answer 25

clopidogrel

7 to 15 days; bridging therapy

Question 26

Difficult BGIT cases and other causes of BGIT – uncommon cause or difficult location that may make endoscopic detection and haemostasis challenging

• Location – high _________ area, incisura, _________ of D1, posterior to scope in the cardia area)
• Conditions – Dieulafoy’s lesions, Cameron ulcer

Cameron lesions – linear erosions in a hiatus hernia, usually ___________ (at GEJ)

• Patients present with chronic or acute pain, usually no abdominal pain but may have reflex symptoms
• Treated with iron and/or PPIs, or endoscopic therapy if high risk

Dieulafoy’s lesions – abnormally large ______________ at the proximal stomach

• Intermittent, painless massive bleeding , difficult to identify at endoscopy
• Endoscopic haemostasis recommended – thermal, mechanical, or combination therapy (adrenaline injection and contact thermal or mechanical)
• ________________ or surgery should be considered if endoscopic treatment fails or not technically feasible

Answer 26

lesser curve; posterior wall

sliding hernia;

submucosal artery; Transcatheter angiographic embolization (TAE)

Question 27

Angioectasias/GAVE – can be a cause of UBGIT specially in advanced renal disease patients
- Gastric antral vascular ectasia – associated with
dilated small blood vessels in the ______________
- __________ – dilated, ectatic, thin-walled vessels in
the mucosa or submucosa
- 2 meta-analyses showed endoscopic haemostasis therapy with APC, heater probe, bipolar/monopolar coagulation, band ligation, YAG laser to be effective and safe
o However, bleeding recurrence rates are significant
o Medical treatment – iron supplementation/ _______

Mallory-Weiss tears
- Mortality similar to bleeding PUD, with risk factors for adverse outcomes: age, comorbidities, active bleeding at endoscopy
- Active bleeding – ______________ recommended
o Mechanical therapy appears safe (insufficient data to
recommend one modality over the other)

Answer 27

pyloric antrum; Angioectasias; thalidomide; endoscopic haemostasis

Question 28

Stress ulcer bleeding
- Once a major cause of morbidity and mortality in critically ill patients
o Much lower now (drop from 15 to 1.5% in ICU patients)
- With improvements in resuscitation and critical care, surgical intervention is only necessary for a small number of patients with life-threatening haemorrhage or perforation from stress ulcers

GI malignancies

• Endoscopic therapy may avert urgent surgery and reduce PCT requirements
• No long term efficacious treatment
• ___________ for bleeding gastric tumours and hemospray is emerging as an option

Answer 28

Radiotherapy