Upper GI Bleed Flashcards
Define the term “Haematemesis”
vomiting up fresh blood
Define the term “Melaena”
passing of black tarry faeces discoloured by the presence of digested blood.
What causes “coffee ground” vomit
caused by vomiting digested blood that looks like coffee grounds.
What is the classic presentation of a patient with an upper GI bleed
Patients commonly present with haematemesis and/or melaena and may have features of shock (e.g. hypotension, collapse).
Name the three causes that account for the majority of upper GI bleeds
Peptic ulcer disease
Gastritis
oesophageal varices
Name the 2 causations of peptic ulcer
Helicobacter pylori
The use of NSAIDs
Name some of the oesphageal causes of upper GI bleed
Varices
Oesphagitis
Maligancy
Name some of the gastric causes of upper GI bleed
Peptic ulcers
Gastritis
Mallory-Weiss
Malignancy
Name some of the duodenal causes of upper GI bleed
Peptic ulcers
Duodenitis
Diverticulum
Aorto-duodenal fistula
What are oesphageal varices
Abnormal, dilated veins that occur at the lower end of the oesophagus
Oesophageal varices occur secondary to portal hypertension most commonly secondary to cirrhosis.
Describe the physiology on how portal hypertension can cause oesphageal varcies
Increases in portal pressure lead to the development of a collateral circulation to overcome the obstruction to flow in the portal system.
The lower end of the oesophagus forms an important ‘portacaval anastomosis’which allows the flow of venous blood from the portal system to the systemic circulation.
Several risk factors increase the likelihood of a patient developing an upper GI bleed.
Name some of these risk factors
NSAIDs
Anticoagulants
Alcohol abuse
Chronic liver disease
Chronic kidney disease
Advancing age
Previous peptic ulcer disease or H. pylori infection
What is the main diagnostic test for upper GI bleed
Upper GI endoscopy
Upper GI endoscopy is the main diagnostic test for upper GI bleed.
Within what time scale should this be completed
immediately in any unstable patient following initial resuscitation
within 24 hours in all other patients
Early risk stratification helps identify high-risk patients & need for prompt intervention.
Name the two scoring systems used in upper Gi bleed
Blatchford score
Rockall
Which upper GI bleed scoring system is recommended during the primary assessment
Blatchford score
Which upper GI bleed scoring system takes into account endoscopy findings
Rockall scoring
Name some of the components of the Blatchford score
Drop in Hb
Rise in urea
Blood pressure
Heart rate
Melaena
Syncope
Why is there a rise in urea in upper GI bleeds
the blood in the GI tract gets broken down by the acid and digestive enzymes.
One of the breakdown products is urea and this urea is then absorbed in the intestines.
What are the components of the Rockall scoring system
Mnemonic ABCDE:
A - Age
B - Blood pressure (and heart rate)
C - Comorbidity
D - Diagnosis
E - Endoscopic findings
What is the most common cause of non-variceal upper GI bleeding
Peptic ulcer disease
The risk of rebleeding of non-variceal upper GI bleeds, which influences the need for intervention, depends on
The endoscopic findings of the ulcer.
If based on the endoscopic findings. If the non-variceal upper GI bleed is deemed high risk of rebleeding
What is the next management option
Endoscopic intervention (Endo-therapy)
What techniques are employed in endo-therapy to treat the bleed
Adrenaline injection
Thermal coagulation by a heater probe
Mechanical e.g. endoscopic clips
Haemostatic powders
(thrombin, laser)
When should IV proton pump inhibitor therapy be considered in the treatment of non-variceal upper GI bleed
in high risk patients and only after endo-therapy
When should you transfuse with fresh frozne plasma
if the patients INR > 1.5 due to coagulopathy.
If the non-variceal bleeding is not controlled by endo-therapy, what is the next management step
radiological embolisation or surgical intervention.
Name the 3 Pharmacological intervention of a variceal upper GI bleed
Terlipressin (IV injection)
Prophylactic antibiotic therapy
Non-selective beta blockers
Terlipressin is an analogue of what hormone
vasopressin (ADH)
Describe the mechanism of action of Terlipressin in managing variceal upper GI bleeds
Causes splanchnic vasoconstriction
This reduces portal pressures
Used only temporarily
What does Prophylactic antibiotic therapy do in the management of variceal upper GI bleed
Helps to reduce rebleeding and mortality
Give an example of a non-selective beta blocker
Propanol
Describe the mechanism of action of non-selective beta blockers in managing variceal upper GI bleeds
Causing splanchnic vasoconstriction
This reduces portal pressure
What is the endoscopic intervention in the management of variceal upper GI bleeds
Variceal band ligation (VBL)
What is involved in Variceal band ligation (VBL)
Rubber bands are put on the varices which occlude the blood vessels and the bands eventually fall off and the collateral should disappear.
How often do patients have to undergo variceal banding programme
every 2-4 weeks until varices have gone.
If the varices are not controlled by endo-therapy and pharmacological intervention then what are the two further options
Trans-jugular intrahepatic stent shunt (TIPS) - first choice failed invention
Sengstaken tube
Which therapy if the 1st choice of failed invention for variceal bleeds
Trans-jugular intrahepatic stent shunt (TIPS)
Describe what is involved in Trans-jugular intrahepatic stent shunt (TIPS)
Interventional radiological procedure.
Radiologist create a shunt between the portal and hepatic vein, which shunts the high pressure blood into the systemic venous circulation to reduce the portal pressure.
Name a potential complication of Sengstaken tube
Bridging therapy
Temporary as at risk of oesophageal necrosis if left > 24 hours.
