tbl 6: upper gi bleeding

Question 1

Clinical presentation in UBGIT
- History – confirm haematemasis (need to differentiate from ____________), _____________ (black tarry stools)
- Medical history – check for _____________, varices or variceal bleed in the past, varices seen on previous OGD, hepatitis B or C history and alcohol intake
- Medications – check if patient is on _________________
Physical examination
- Check for vital signs – pulse rate, blood pressure etc. to make sure patient is stabilized
- General – pallor, jaundice, conscious level, presence of ________________
- Peripheral stigmata of chronic liver disease – ____________
- Abdominal examination – ascites, splenomegaly (suggestive of portal hypertension), hepatomegaly, caput medusae

Answer 1

hemoptysis; melena

known liver cirrhosis;

antiplatelet or anticoagulants;

encephalopathy;

spider naevi, palmar erythema, gynecomastia

Question 2

Resuscitation – important to stabilise the patient
- Check ABC (airway, breathing, circulation)
- If patient is actively vomiting or patient is drowsy, consider ___________ to protect the airway
- Monitor blood pressure and heart rate – important to note that patient may have normal heart rate if on _______________
o If there is low blood pressure, start IV fluids, usually normal saline
- Aim for Hb 7 to 8 (unless there is underlying ischemic heart disease)
- Avoid over-transfusion or over-resuscitation – will increase _______________and induce of rebleeding (especially for variceal bleeding
- FFP or platelets can be considered depending on the _______________

Answer 2

intubation;

beta blockers;

portal pressure ;

platelet and INR levels

Question 3

Differential diagnoses for variceal UBGIT

• Peptic ulcer
• Tumours
• _______________ – results in bleeding from oesophagus due to chronic vomiting and retching
• Vascular ectasias/arterio-venous malformations
• ___________ – large tortuous arteriole most commonly in the stomach wall (submucosal) that erodes and bleeds
• Erosions
• Oesophagitis

Answer 3

Mallory Weiss tear;

Dieulafoy’s lesion

Question 4

Management of variceal UBGIT
- Firstly, stabilise the patient
- Pharmacologic therapy
o IV proton pump inhibitors e.g. _____________ – initially unable to differentiate from peptic ulcer bleed
o IV __________________ – to decrease portal blood flow
§ IV somatostatin is used in TTSH (250mcg stat followed by 250mcg/h infusion)
§ Somatostatin decreases portal pressure and collateral blood flow by inhibiting release of ____________
- Following a variceal bleed, blood in the GI tract acts like a meal, leading to an increase in portal flow and elevation of portal pressure – ameliorated by somatostatin
o This is continued even after endoscopic variceal haemostasis is achieved (up to 3 to 5 days)
- Antibiotics prophylaxis – integral part of therapy for patients with cirrhosis presenting with upper GI bleeding
o Usually ______________ stat dose then once daily dose

Answer 4

omeprazole;

somatostatin/octreotide/terlipressin;

glucagon;

IV ceftriaxone 1mg

Question 5

Endoscopy – plan for OGD preferably within _____________
o Check with patient when his/her last meal/drink was
o In the absence of contraindications (______________), pre-endoscopy infusion of _____________ should be considered

Oesophageal varices

• Usually at the ________________
• ______________ is the preferred endoscopic modality for acute oesophageal variceal bleeding

Gastric varices
- Usually at the __________
- _________________ is attempted for gastric variceal bleeding
- Failure of endoscopic management – _________________
o Temporary and not definitive treatment – not to remain in situ for more than 24 hours
o Bridging till definitive treatment of repeat scope or TIPSS/BRTO

Answer 5

12 hours of presentation;

QT prolongation;

erythromycin;

lower third of the oesophagus;

Endoscopic variceal ligation;

fundus;

Histoacryl glue injection;

Sengstaken-Blackmore tube placement

Question 6

Transjugular intrahepatic porto-systemic shunt
(TIPSS)
o Reduces elevated portal pressure by creating a communication between the __________________
o Functions as a shunt to treat complications of portal hypertensions such as variceal bleeding and refractory ascites
o Indications – failed endoscopic hemostasis of varices, rebleed of varices despite endoscopic therapy

o Early TIPSS (within 72 hours) should be considered in patients with variceal bleeding at high risk of treatment failure e.g. _________________ or Child’s Pugh score B with active bleeding

Answer 6

hepatic vein and portal vein;

Child’s Pugh score < 14

Question 7

Balloon occluded retrograde transvenous obliteration (BRTO) – procedure used for treatment of gastric fundal varices with a ____________________
o ______________ is cannulated followed by balloon occlusion and slow infusion of sclerosant to obliterate the gastro/splenorenal collateral and fundal varices
o BRTO may increase portal pressure and worsen complications such as ascites or oesophageal varices

Answer 7

large gastrorenal or splenorenal collateral;

Left renal vein

Question 8

Management after haemostasis
- Prevention of recurrent variceal haemorrhage – nonselective beta blockers e.g. propranolol, nadolol
o Blockage of β1-adrenergic receptors in the heart ________________________
o Blockage of β2-adrenergic receptors causes ______________________ – allows unopposed action of α1-adrenergic receptors and results in decreased portal blood flow
o Combination of decreased cardiac output and portal flow leads to decrease in portal pressure
- Variceal eradication – repeat OGD with variceal ligation every 1 to 4 weeks until eradication of varices (no more ligation needed)
o If patient had TIPSS placed successfully, there is no need for beta blockers and variceal eradication

Answer 8

decreases cardiac output;

vasodilatation in mesenteric circulation