Upper GI bleed Flashcards by Roksana Świderska

Causes of upper GI bleed (oesophageal)

Oesophageal causes of upper GI bleed

varies
oesophagitis
cancer
Mallory-Weiss tear

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Causes of gastric bleeding

gastric Ca
diffuse erosive gastritis
Dieulafoy lesion
gastric ulcer

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What is the most common cause of major upper GI hemorrhage?

Posteriorly sided duodenal ulcer

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What should patients with suspected varices receive propr to the endoscopy

Terlipressin - it is a vasopressin analogue -> vasoconstriction caused

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Management of upper GI bleed

early control of airway + resuscitation if needed
investigate: bloods, upper GI endoscopy within 24 hours
further Rx depends on the cause of hemorrhage

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Treatment of oesophageal varices causing upper GI bleed

banding
sclerotherapy

If these do not work:

Sengaksten- Blakemore tube (or Minnesota tube)

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Treatment of patients with erosive oesophagitis / gastritis

Erosive oesophagitis/ gastritis Rx

proton pump inhibitor
identifiable bleeding points -> combination therapy of injection of adrenaline and either a thermal or mechanical treatment.
all patients who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.

* Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy

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Which vessel is usually involved in the bleeding in duodenal ulcer

Gastro-duodenal a.

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which vessel is usually involved in the bleeding from the gastric ulcer

left gastric artery

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What score is used to predict the severity of upper GI bleed? (if admission and endoscopy is needed)

Blatchford score

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What are the components of Blatchford score assessment?

Patient’s: Hb, serum urea, pulse rate and BP

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What indicates low and what indicates a high risk on Blatchford score?

patients with a score of 0 are low risk
all others are considered high risk and require admission and endoscopy

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What to calculate following the endoscopy? Why?

Rockall score - to determine the patient’s risk of rebleeding and mortality

* A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge

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Rx for Mallory Weiss tear

Mallory Weiss tears will typically resolve spontaneously

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Surgical treatment for duodenal ulcer

Duodenal ulcer - surgery

Laparotomy, duodenotomy and under running of the ulcer

*duodenotomy - excision of parts or all of the duodenum

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Treatment (surgical) for bleeding gastric ulcer

Under-running of the bleeding site - suture ligation /podwiazanie/ of the bleeding vessel
Partial gastrectomy-antral ulcer
Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery)
Total gastrectomy if bleeding persists

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What does Haematochezia mean?

Haematochezia

/hematoczesja/

Passing fresh blood - blood does not have time to be altered

*passed usually PR

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What two groups of meds are associated with upper GI bleed

Drugs to be asked about while taking a history from a patient with an upper GI bleed

A. Mucosal damage (e.g. NSAIDs)

B. Impaired hemostasis(e.g. Warfarin)

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Drugs that may cause mucosal damage (contributing to an upper GI bleed)

Mucosal damage:

NSAIDs
COX 2 inhibitors
Prednisolone

*all steroids, all anti-inflammatory (e.g. Naproxen, Ibuprofen, Diclofenac)

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Drugs that impair hemostasis (therefore may impact on upper GI bleed)

Drugs that impair haemostasis:

Warfarin
DOACs / NOACs
Heparin/LMWH
anti-platelets
clopidogrel
Aspirin

What does support the diagnosis of GI bleed? (4)

Hx of melena
Melena on PR
ratio of blood urea nitrogen to serum -> urea will go up
creatinine greater than 30

What is the Rockall score used for?

What is the Blatchford (Glasgow-Blatchford) score used for?

Rockall score -> to predict mortality
Glasgow - Blatchford -> to see who we need to admit

What does go up with upper GI bleed?

Urea goes up

What score on Blatchford scale would indicate the need for admission (and need for upper endoscopy)?

Score of 1 or more

(only score of 0 indicated low risk -> so pt can be discharged)

What signs are suggestive of upper GI bleed?

* are they hypotensive? (\>15% postural drop) * tachycardia

**Classes of an acute haemorrhage** What is important to know?

Important: a patient with a significant bleed (1500 or above) will show signs \*Signs: tachycardia, hypotension, decreased urine output, reduced LOC

How much blood is lost in an acute haemorrhage?

**Class I** (\<750) 15% **Class II** (750 - 1500) 15 - 30% **Class III**(1500 - 2000) 30-40% **Class IV** (\>2000) \>40%

What do we need to consider in terms of ***hemorrhage*** in a patient who is on ***beta-blocker***?

HR rate may not be up even with a significant bleed

The lethal **triad of coagulopathy** - what does it involve?

* hypothermia * acidosis * coagulopathy ## Footnote (lethal triad applies to each acute bleeding)

**What Dx would be these elements in Hx indicative of?** - NSAID use, previous ulcer, systemic illness

* peptic ulcer disease * gastroduodenitis

**What Dx of upper GI bleed would be these elements in Hx indicative of?** - Alcohol excess, chronic liver disease, spider naevi, jaundice, hepatosplenomegaly, encephalopathy, ascites

Varices/ portal hypertensive gastropathy

**What Dx of upper GI bleed would be these elements in Hx indicative of?** - excessive retching and vomiting prior to haematemesis

Mallory-Weiss tear

**What Dx of upper GI bleed would be these elements in Hx indicative of?** - weight loss, dysphagia

- stricture - malignancy

**What Dx of upper GI bleed would be these elements in Hx indicative of?** - chronic reflux, bisphosphonate use

Oesophagitis

**What Dx of upper GI bleed would be these elements in Hx indicative of?** Previous abdominal aortic aneurysm repair

aorto-enteric fistula

**What Dx of upper GI bleed would be these elements in Hx indicative of?** Chronic kidney disease

***Vascular ectasia*** - dilated small blood vessels in pyloric antrum -\> bleeding into intestine - it is known as 'watermelon stomach' - due to pattern of bleed and appearance

**What Dx of upper GI bleed would be these elements in Hx indicative of?** Recent ERCP

***Post- sphincterotomy*** bleed

**What Dx of upper GI bleed would be these elements in Hx indicative of?** Peritonitis

Perforated ulcer

**What Dx of upper GI bleed would be these elements in Hx indicative of?** cachexia/lymphadenopathy

malignancy

Investigations in pt coming with upper GI bleed

- **FBC** -\> hemoglobin may not be yet decreased in acute bleed - **U+E** -\> to see urea levels (up in the bleed) - **LFTs** -\> due to the impact of chronic liver disease - **glucose** -\> check for hypoglycemia - **G+S +/-** **cross match** - **ECG** -\> to see if bilirubin has an effect on the heart **-** **errect** **CXR** -\> to see for perforation \*G+S if pt reports bleeding but obs stable and appears well \* cross match - if pt is unstable

Do we give PPI before the endoscopy?

Not according to NICE guidelines \*may affect the results of biopsy if to be taken during endoscopy

Management of upper GI bleed (in general) - meds wise - non-meds wise

_Meds:_ - IV ***Metoclopramide*** (anti-emetic) - IV n***Terlipressin*** (if Hx suggestive of varices - to vasoconstrict) - blood transfussion -\> if indicated - IV ***vitamin K/FFP/ platelets*** -\> if indecated _Other:_ - endoscopic options

Surgical options of management of upper GI bleed

Options depend on the source/cause of bleeding: - embolization (cut off blood supply to the bleeding) - TIPS - transplantation

Risk factors for bleeding of the varices

- variceal size -\> the bigger they are - the more chances of bleed - the presence of endoscopic red color signs (e.g. cherry red spots, red markings) - active alcohol use - Child classification -\> to classify severity of liver disease -\> more severe = more likely to bleed

What scale is used to classify the severity of liver disease?

The ***Child - Pugh*** classification

Why do we give antibiotic for a patient with upper GI bleed?

When a patient is encephalopathic -\> change of the gut bacteria (translocation) -\> release of endotoxin into systemic circulation -\> sepsis and hemodynamically unstable

Thresholds and Mx for coagulopathy: - platelets - INR - aPTTr - Fibrinogen

What to advice on the discharge of pt after upper GI bleed (if the cause was ulcer)

* H-pylori treatment (if present) * Ulcers: PPI for an initial period of 6-8 weeks * Ulcers: stop NSAIDs/ Cox 2 inhibitor * Perhaps clopidogrel * if pt needs to take anti-inflammatory -\> consider COX 2 inhibitor * if aspirin is needed -\> prescribe PPI with it * repeat endoscopy in 6-8 weeks -\> to ensure the healing and exclude malignancy