Upper GI Bleeding

Question 1

ESSENCE

Answer 1

Pathogenic bleeding in upper GI tract proximal to ligament of Treitz (suspensory ligament where duodenum transitions to jejunum)

Question 2

AETIOLOGY

Most common causes above GE junction

Answer 2

• Epistaxis
• Oesophageal varices
• Oesophagitis
• Oesophageal cancer
• Mallory-Weiss tear

Question 3

AETIOLOGY

Most common causes in stomach

Answer 3

• Gastric ulcer
• Gastritis
• Gastric cancer
• Gastric antral vascular ectasia

Question 4

AETIOLOGY

Most common causes in duodenum

Answer 4

• Duodenal ulcer
• Aortoenteric fistula

Question 5

AETIOLOGY

Risk factors

Answer 5

• Alcohol
• Smoking
• Liver disease
• Chronic vomiting
• History of peptic ulcer disease
• Repeated NSAID/aspirin use

Question 6

EPIDEMIOLOGY

Are most bleeds upper or lower

Answer 6

Upper (75%)

Question 7

CLINICAL FEATURES

Presentation

Answer 7

• In order of severity from most to least
  
  • Haemochezia, haematemesis, melena, occult blood in stool
  • Haematemesis
  • Melena
• Malaise/weakness
• Fever

Question 8

CLINICAL FEATURES

Signs

Answer 8

• Tachycardia, fever
• Poor capillary refill, pale conjunctiva
• Orthostatic hypotension

Question 9

INVESTIGATIONS

First choice

Answer 9

• Endoscopy first choice
• Serum labs
  
  • FBC
  • Coagulation studiers (PT/PTT/INR)

Question 10

MANAGEMENT

General principles

Answer 10

• Resuscitation - ABCDE
  
  • Intubation, IV fluid, blood transfusion
• Treatment underlying condition
  
  • IV proton pump inhibitor for peptic ulcer disease
• Surgical options to address underlying cause

Question 11

MANAGEMENT

Surgical options

Answer 11

• Epinephrine injection and thermal haemostasis - peptic ulcers
• Endoscopic banding or sclerotherapy - oesophageal varices
• Open surgical procedure - only indicated in severe bleed
• Transjugular intrahepatic portasystemic shunt (TIPS) - consider in recurrent variceal bleeding