Upper GI bleed

Question 1

What are the causes of an upper GI bleed? (list, don’t explain)

Answer 1

Oesophagitis
Oesophageal varices
Mallory-Weiss tear
Oesophageal cancer
Gastritis
Gastric or duodenal ulcer
Gastric varices
Gastric carcinoma (Rare)
Haemorrhagic gastropathy and erosions
Duodenitis

Question 2

How does an Upper GI bleed present?

Answer 2

Haematemesis is the vomiting of blood. Blood might be bright red or ‘coffee-ground’. Melaena means black motions, often like tar and has a characteristic smell of altered blood. Both indicate an upper GI bleed

Question 3

What is oesophagitis and what causes it?

Answer 3

Oesophagitis is an inflammation of the lining of the oesophagus

It is usually due to gastro-oesophageal reflux. Other causes include NSAID, herpes, candida, duodenal or gastric ulcers or cancer, non-ulcer dyspepsia, sphincter or oddi malfunction and cardiac disease

There may be a history of heart burn, indigestion or painful swelling.

Question 4

What are oesophageal varices, how do they arise, and how are they treated?

Answer 4

Oesophageal varices
= Collateral veins that form in response to portal hypertension and allow portal blood to bypass the liver and enter the systemic circulation directly. Most common causes is hepatic cirrhosis.

Endoscopy should be arranged after resuscitation, within 4hours of a suspected variceal haemorrhage

Treatment:
1) Endoscopic variceal banding – suck up varix into a chamber and place an elastic band around the varix.

2) Balloon tamponade – uses a balloon to compress the oesophageal varices – this direct pressure reduces bleeding until transfer and further surgery is available.

3) Re-bleeding is common and is worse with large varices
– Varices should be suspected if there is alcohol abuse or cirrhosis. Look for signs of chronic liver disease, encephalopathy, splenomegaly, ascites, hyponatraemia, coagulopathy and thrombocytopaenia

Prophylactic treatment:

1) Non-selective B-Blockers: propranolol
2) endoscopic banding ligation

Question 5

What is a mallory-weiss tear and what causes it?

Answer 5

Mucosal tear in the oesophageal-gastric junction, following increased gastric pressure. The history includes forceful retching with initially non-bloody vomit, followed by haematemesis.

Question 6

What causes gastritis, how does it present, how can it be prevented and how is it treated?

Answer 6

Causes:
Alcohol, NSAIDs, H. Pylori, reflux/hiastus hernia, atrophic gastritis, granulomas (Crohn’s, sarcoidosis), CMV, Zollinger- Ellison’s

Presentation:
Epigastric pain, vomiting, haematemesis

Prevention:
Give PPI gastroprotection with NSAIDs, this also prevents bleeding from acute stress ulcers gastritis so often seen with ill patients on ICU.

Treatment:
Ranitidine or PPI, eradicate H. Pylori if needed