Upper GI bleed

Question 1

Examination

Answer 1

• Signs of chronic liver disease 
- Spider naevi 
- Ascites 
- Caput meduca 
- Rectal varices
• melaena
• Shock?
- Cool, clammy, Cap refill >2s
- ↓BP (<100) 
- ↓ urine output 
- Tachycardia
- Confusion

Question 2

Common Causes

Answer 2

• peptic ulcer disease (DU commonly)
• Acute erosions/ gastritis
• Mallory-Weiss tear
• Oesophageal varices
• Oesophagitis
• gastric or oesophageal CA

Question 3

Rockall Score:

Answer 3

• Prediction of re-bleeding and mortality
• Initial score pre-endoscopy
• Age
• Shock: BP, pulse
• Comorbidities

• Final score post-endoscopy

• Final diagnosis + evidence of recent haemorrhage
• Active bleeding
• Visible vessel
• Adherent clot

• Initial score ≥3 or final >6 are indications for surgery

Question 4

Oesophageal varices

Answer 4

• Portal HTN causes dilation of L. gastric and inferior oesophageal veins

Mx:

• Terlipressin IV
• 2 of: banding, sclerotherapy, adrenaline injection, coagulation

• TIPSS if bleeding can’t be stopped endoscopically

• Balloon tamponade with Sengstaken-Blakemore tube
- if haemorrhage worse or failure of endoscopic therapy

Question 5

Transjuglar Intrahepatic Porto-Systemic Shunt

TIPSS

Answer 5

• artificial channel between hepatic vein and
portal vein → ↓ portal pressure.
• Tract through liver
parenchyma which expands using a balloon and maintained by placement of a stent.
• Used prophylactically or acutely if endoscopic therapy fails to control variceal bleeding

Question 6

Terlipressin

Answer 6

Vasopressin analogue

Inhibits nitrous oxide release causing vasoconstriction and decreases portal venous blood flow

Question 7

Prophylactic abx

Answer 7

Ciprofloxacin

Question 8

Oesophageal ulcer mx

Answer 8

• Adrenaline injection and either:

• Thermal / laser coagulation
• Fibrin glue
• Endoclips

Question 9

Afterr endoscopy

Answer 9

• Omeprazole IV + continuation PO
• Keep NBM for 24h → clear fluids → light diet @ 48h
• Daily bloods: FBC, U+E, LFT, clotting
• H. pylori testing and eradication
• Stop NSAIDs, steroids

Question 10

Indications for Surgery

Answer 10

• Re-bleeding
  • Bleeding despite transfusing of 6 units
  • Uncontrollable bleeding at endoscopy
  • Initial Rockall score ≥3, or final >6.