Upper GI Bleed

Question 1

What is used to differentiate upper GI from lower GI bleed?

Answer 1

Raised urea

Question 2

What are the clinical features of upper GI bleed?

Answer 2

haematemesis
the most common presenting feature
often bright red but may sometimes be described as ‘coffee ground’
melena
the passage of altered blood per rectum
typically black and ‘tarry’
a raised urea may be seen due to the ‘protein meal’ of the blood
features associated with a particular diagnosis e,g,
oesophageal varices: stigmata of chronic liver disease
peptic ulcer disease: abdominal pain

Question 3

How does oesophagitis present?

Answer 3

Small volume of fresh blood, often streaking vomit. Melena rare. Often ceases spontaneously

Question 4

How does Mallory Weiss tear present?

Answer 4

Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Melena is rare. Usually ceases spontaneously

Question 5

How does gastric cancer present?

Answer 5

May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage

Question 6

How does gastric ulcer present?

Answer 6

Small low low-volume bleeds are more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.

Question 7

Which gastric ulcers are likely to perforate?

Answer 7

Anterior ulcers

Question 8

Which gastric ulcers are prone to bleeding?

Answer 8

Posterior ulcers

Question 9

What is dieulafoy lesion?

Answer 9

Large turtous submucosaucosal artery casing bleeding. Didficult to detect endoscopically.

Question 10

What are the duodenal causes of bleedingding?

Answer 10

Posterioriro duodenal ulcer
Aorta-enteric fitsula

Question 11

What is diffuse erosive gastritis?

Answer 11

Diffusive Erosive gastritis is erosion and stomach ulcers throughout stomach caused by alcohol, NSAIDs and stress. Presents with epigastric discomfort and haematemesis

Question 12

What is the risk for aort-enteric fistula?

Answer 12

In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.

Question 14

What are the features of Glasgow blatchford score?

Answer 14

High urea levels
Hb low
Systolic blood pressure low
Tachycardia

Question 15

What scores highly in Glasgow blatchford?

Answer 15

Urea over 25

->urea over 6.5 is at least 2 points
SB less than 90
Liver disease/cardiac/failure

Question 16

What is used for management I of bleeding in those taking warfarin?

Answer 16

Prothrombin complex concentrate

Question 17

What is offered for transfusion for those with low fibrinogen level?

Answer 17

Fresh frozen plasma
-> offered if PTT time greater than 1.5x

Question 18

What should be avoided before endoscopy?

Answer 18

PPIs

Question 19

What is the management of variceal bleeding?

Answer 19

terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices

Question 20

What should be offered for patients with uncontrolled bleeding?

Answer 20

TIPS

Question 21

Rockall score 3 points? l

Answer 21

Liver disease cardiac disease or metastatic disease

Question 22

Rockall score 2 points?

Answer 22

Age over 80
Hypotension
Any comorbidities except liver, renal and metastasis
Malignancy of upper GI
Stigmata of bleed

Question 23

What is the stigmata of major bleed?

Answer 23

Blood in upper GI tract
Adherent tract
Spurting vessel