Upper GI bleed

Question 1

Causes

Answer 1

Peptic ulcer disease (GU/DU)
Oesophageal-gastric varices
Oesophagitis
Gastritis/erosions/erosive duodenitis
Maliganancy
Mallory-Weiss tear
Vascular malformation

Thinking of differentials: oesophageal, gastric and duodenal

Question 2

Gastric ulcer

Answer 2

Tends to be small, low volume bleeds -> present as Fe deficiency anaemia
Erosion into significant vessel -> haemorrhage and haematemesis
Epigastric pain worse after eating

Question 3

Duodenal ulcer

Answer 3

Haematemesis, melaena, epigastric discomfort

Pain several hours after eating

Question 4

Varices

Answer 4

Large volume fresh blood
Melaena
Haemodynamic compromise
May spontaneously stop - rebleeds common if not appropriately managed

Question 5

Oesophagitis

Answer 5

Small volume fresh blood - often streaking vomit
Melaena rare
Often ceases spontaneously
Usually preceded by GORD type symptoms

Question 6

Gastritis/erosions

Answer 6

Haematemesis and epigastric discomfort
Underlying cause eg recent NSAIDs
Low volume haemorrhage with significant haemodynamic compromise

Question 7

Oesophageal malignancy

Answer 7

Small volume of blood
Dysphagia and systemic symptoms (weight loss)
Recurrent until malignancy managed
Erosion of major vessels -> haemorrhage: pre-terminal event

Question 8

Gastric malignancy

Answer 8

Volume variable. Erosion of major vessel -> big haemorrhage
Frank or mixed with vomit
Dyspepsia and systemic symptoms

Question 9

Mallory-Weiss tear

Answer 9

Brisk small to moderate volume of bright red blood following repeated vomiting
Melaena rare
Ususally ceases spontaneously

Question 10

Risk factors for GI bleed

Answer 10

Alcohol abuse
Chronic renal failure
NSAIDs, aspirin, corticosteroids
Increasing age
Low SES

Question 11

Risk factors for re-bleeding

Answer 11

>60 yo
Signs of shock at admission
Coagulopathy
Pulsatile haemorrhage
Cardiovascular disease

Question 12

Presentation

Answer 12

Abdominal pain
Haematemesis (higher mortality than melaena alone), coffee-ground (implies bleeding ceased or relatively modest), melaena, haematochezia
Shock, syncope
Features of underlying cause (dyspepsiam weight loss, jaundice)
Risk factors
PMH of bleeding

Question 13

Examination

Answer 13

Pallor (anaemia)
Pulse, lying and standing BP (postural hypotension indicates blood loss >20%)
Signs of shock
Abdo pain
Signs of dehydration
Signs of liver disease
Signs of malignancy

Question 14

Investigations

Answer 14

Bloods: FBC, U+E, LFT, amylase, coag, crossmatch, calcium
Endoscopy: Immediately after resus if unstable, withing 24 hours otherwise
CXR: aspiration pneumonia, pleural effusion, perf oesophagus/bowel
AXR: bowel perforation
CT: liver disease, pancreatitis with haemorrhage and pseudocyst, cholecystitis with haemorrhage, aorto-enteric fistula
Angiography if endoscopy fails to find bleeding site

Question 15

Risk assessment

Answer 15

Blatchford score: Likelihood that patient will need intervention. 0 = early discharge and O/P F/U; >6 = transfusion and early I/P investigation

Rockall score: after endoscopy; identifies patients at risk of adverse outcome. <3 = good prognosis; >8 = high risk of mortality

Question 16

Initial management

Answer 16

Resus

Endoscopy

Question 17

Management of non-variceal bleeds

Answer 17

Endoscopically: Clips +/- adrenaline; thermal coagulation + adrenaline; fibrin or thrombin + adrenaline
PPIs: do not offer before endoscopy; offer if non-variceal and signs of recent haemorrhage at endoscopy
After failed first endoscopic treatment: Repeat endoscopy + treatment if high risk of rebleed or do rebleed; interventional radiology if unstable + rebleed

Question 18

Management of variceal bleeds

Answer 18

Terlipressin at admission if suspected variceal bleed - continue until definite haemostasis or for 5 days
Prophylactic abx at presentation
Oesophageal: Band ligation; consider transjugular intrahepatic portosystemic shunts (TIPS) if not controlled by band ligation
Gastric: Endoscopic injection of N-butyl-2-cyanoacrylate; offer TIPS if not controlled by N-butyl-2-cyanoacrylate

Question 19

Prevention of rebleeding in patients on NSAIDs, aspirin or clopidogrel

Answer 19

Continue aspirin for secondary prevention of cardiovasular events if haemostasis acheived
Stops NSAIDs during acute phase
Discuss risk/benefit of clopidogrel with specialist and patient

Question 20

Primary prophylaxis in critical care

Answer 20

Offer H2-receptor antagonist or PPI for acutely unwell patients in critical care
Review continued need on discharge