UGI Bleeds - Bleeding/perforated peptic ulcer, Mallory-Weiss, Boerhaave, Esophageal varices

Question 1

Peptic ulcer disease (acute bleeding)
-possible source of bleeds
-presentation
-treatment additional to UGI bleed management

Answer 1

Gastroduodenal most common as it lies posterior to duodenum

Hematemesis, melena
Shock

IV PPI
1st line - endoscopic clipping/thermal coagulation/adrenaline injection
2nd line - urgent angio with transarterial embolisation/surgery

Question 2

Perforated peptic ulcer
-pathophysiology
-risk factors
-presentation

Answer 2

Complete erosion of ulcer through stomach/duodenum => peritoneal cavity
-peritonitis, irritation => pain, rigidity, tender, distended

HPylori
NSAIDs
Smoking

Hx of peptic ulcer disease
Severe epigastric abdo pain => generalised
Referred pain to shoulder tip
Peritonitis (guarding, rigidity, rebound tenderness)
Abdo tender, distention
N+V, fever

Upright C/AXR => pneumoperitoneum

Initial resus
-drip and suck (IV fluids, NBM, NG tube insertion to reduce gastric fluid from continuing to leak)
-ABx

Non-operative if stable, improving after resus
Operative if continuing to deteriorate
-surgical closure of perforation

UGI endoscopy to identify cause of perforation => treat

Question 3

Mallory-Weiss tear
-pathophysiology
-risk factors
-presentation
-investigations
-management

Answer 3

Forceful vomiting => incomplete tear in distal esophagus/proximal stomach and underlying vasculature

Predisposing - alcohol, hiatus hernia, GERD
Precipitating - severe vomit, cough,

Hematemesis, abdo pain
OH if severe bleeding
Melena

UGI endoscopy once stable

Mainly self-limiting, focus on stabilisation

Question 4

Boerhaave’s syndrome
-pathophysiology
-risk factors
-presentation
-investigations
-management

Answer 4

Repeated vomiting => full tear of esophagus

Sudden severe chest pain
-can have subcut chest emphesyma
HIGH SEPSIS RISK
BLOOD LOSS LESS LIKELY

CT contrast swallow

Thoracotomy and lavage
-U12 hrs => primary repair
-12hrs+ => controlled T tube fistula

Question 5

Variceal hemorrhage
-pathophysiology
-risk factor
-presentation
-management

Answer 5

Portal HTN from cirrhosis => esophegeal varices, risk of rupture

Hematemesis - bright red
Melena
May be shocked

Acute A-E
-FFP, VitK, platelet, blood transfusions
-terlipressin, prophylactic quinolones
-endoscopic band ligation

Prophylaxis
-propanolol - reduce rebleeding, mortality
-endoscopic band ligation + PPI cover
-TIPS if above not enough

Question 6

Acute UGI bleeding
-cause types
-risk assessments and when to use them
-management

Answer 6

Variceal - esophageal
Non-variceal - most commonly peptic ulcers

Blatchford before endoscopy - find patients suitable for OP management
-0 = low complication risk
Rockall after endoscopy - estimate death/rebleed risk
-U3 = good prognosis
-8+ = high death risk

Resus - A-E, 2 wide bore IV cannulas
-Active bleed, platelets U50x10^9g/L => platelet transfusion
-Fibrinogen U1g/L or INR/aPTT 1.5x than normal => FFP
-Warfarin + active bleed => PT complex

Endoscopy after resus within 24hrs

Non variceal bleed
-terlipressin and prophylactic ABx => endoscopic coagulation/clips/adrenaline
-if not successful => IR, surgery
-IV PPI AFTER ENDOSCOPY

Variceal bleed
-before endoscopy - terlipressin and prophylactic ABx
-band ligation - esophageal
-Nbutyl2cyanoacrylate - gastric
-TIPS if above unsuccessful

Question 7

Boundary between LGI and UGI

Answer 7

DJflexure - ligament of Treitz