Upper GI bleeding

Question 1

How many admission are there in Australia per year for upper GI bleeds?

Answer 1

40,000

Question 2

What percentage of UGIB are variceal vs. non-variceal?

What are the causes of non-variceal bleeding?

Answer 2

Variceal 12%
Non-variceal 88%
- peptic ulcer disease 33%
- mallory-weiss tear 11%
- cryptogenic 11%
- oesophagitis 8%
- gastritis 5.4%
- malignancy 4%

Question 3

What is the transfusion threshold for UGIB?

What is restrictive transfusion practices based on?

Answer 3

Hb <70

Based on 2013 NEJM article showing reduced rates of adverse events, rebleeding and better survival at 6 weeks

Question 4

What pre-endoscopy score is used to triage the urgency for scopes or an UGIB?

Answer 4

Blatchford score

Question 5

What scoring systems help guide timing of discharge following non-variceal UGIB?

Answer 5

1. Forrest score
2. Rockall score
3. AIM 65 score

Question 6

What effect does PPI therapy have in non-variceal UGIB?

Answer 6

Pre-endoscopy:

• Reduces high risk stigmata seen at endoscopy
• Reduces need for intervention at endoscopy
• Has no effect on mortality, rebleeding, progression to surgery

Post-endoscopy:
for those with high-risk ulcers, high-dose PPI:
- reduced mortality
- reduced rebleeding
- reduced hospital stay 
- reduced transfusion requirements

Question 7

What endoscopic therapies are used for non-variceal UGIB?

Answer 7

“Clip, inject, cauterize”
Use dual therapy: i.e. adrenaline followed by clips
Failing this:
- “bear” clip (STING TRIAL)
- endoscopic spray (salvage therapy, high rates of rebleeding)
- last line is radiological or surgical intervention

Question 8

Variceal bleeding:

1. What percentage of those with cirrhosis develop varices per year?
2. What percentage of those with cirrhosis go on to develop varices over their lifetime?
3. What percentage have a variceal bleed per year?

Answer 8

7% per year
75% over lifetime
5-15% risk of variceal bleeding per year

Question 9

What factors increase the risk of variceal bleeding?

Answer 9

1. Varix size (large varices have 30% annual bleeding risk)
   
   2. Child class: C>B>A
   3. Endoscopic stigmata: red sign, red wale mark
   4. Continued alcohol abuse
   5. Hepatic venous pressure gradient (HVPG) >12 mmHg
      
      6. Previous bleed 60-70%

Question 10

What is the treatment for variceal UGIB?

Answer 10

1. restrictive transfusion
2. octreotide or terlipressin for 5 days
3. antibiotics - ceftriaxone then norflox for 7 days
4. PPI - little evidence
5. Endoscopy with varix banding