Upper GI bleeding

Question 1

How does upper GI bleeding present?

Answer 1

• Active upper gastrointestinal bleeding most commonly presents presents as bright red haematemesis, coffee ground vomiting, or/and melaena
• Patients with the combination of both haematemesis and melaena typically have rapid bleeding, and their mortality is up to twice that of those with either symptom in isolation

Question 2

What is haematemesis?

Answer 2

vomiting of bright red blood

Question 3

What is coffee ground vomiting?

Answer 3

vomiting of dark coloured, granular material resembling coffee grounds

Question 4

What is melaena?

Answer 4

loose, black, tarry stools with a characteristic offensive odour

Question 5

What is upper vs lower GI bleeding?

Answer 5

Upper GI bleeding is defined by a bleeding source proximal to the ligament of Treitz, a suspensory muscle attaching to the duodenojejunal flexure

Question 6

Why does melaena have its distinct colour?

Answer 6

Blood released above the ligament of Treitz is partially digested during passage through the GI tract, accounting for the appearance of melaena

Question 7

What does hematemesis implY?

Answer 7

normally implies active upper gastrointestinal bleeding

Question 8

What does coffee ground vomiting indicate?

Answer 8

Coffee ground vomiting usually suggests that the bleeding is less profuse, has ceased, or is intermittent in nature

Question 9

How does lower GI bleeding present?

Answer 9

Lower GI bleeding usually presents as red or maroon coloured rectal bleeding (haematochezia), although less commonly it may occur where upper tract haemorrhage is profuse or particularly brisk (known as “rapid transit”)

Question 10

What can meleana also arise from aside from upper GI bleed?

Answer 10

Melaena may also arise from ingested blood, in which case inspection of the nares (nostrils) and oropharynx can identify a non-gastrointestinal source of bleeding, for example epistaxis or gingival bleeding.

Question 11

Other causes of coffee ground vomiting?

Answer 11

Dark vomitus from small bowel obstruction can be initially mistaken for haematemesis. Additionally, sepsis or myocardial ischaemia may present with vomiting, especially in older people

Question 12

What are the causes of upper GI bleed?

Answer 12

• Most commonly Peptic ulcers (up to 50% of cases)
• Gastric and duodenal erosions (up to 15%)
• Esophagitis (up to 15%)
• Mallory Weiss syndrome (up to 15%)
• Esophageal varices (up to 10%)
• Rare causes include GI malignancy and vascular malformations

Question 13

Risk factors for peptic ulcers

Answer 13

Risk factors primarily include irritant drug use (predominantly non-steroidal anti-inflammatory drugs) and Helicobacter pylori infection.

Question 14

What is Mallory-Weiss syndrome?

Answer 14

A linear tear at the gastro-oesophageal junction which may resolve spontaneously without the need for endoscopic intervention

Question 15

Esophageal variceal bleed mortality rate

Answer 15

About 30%

Question 16

Aim of initial assessment in upper GI bleeding

Answer 16

• Determine the severity of bleeding
• Estimate the volume of blood loss
• Assess the potential cause and site of haemorrhage
• Determine the patient’s premorbid fitness, comorbid conditions, and potential contributing medications
• Identify if the patient is at high risk of rebleeding or death and so may require urgent endoscopic, radiological, or surgical intervention.
• Consider whether the patient is suitable for a medical ward, or requires admission to an ICU or HDU.

Question 17

Score used to assess Upper GI bleed risk and what is it

Answer 17

The Glasgow-Blatchford bleeding score (GBS) is a screening tool to assess the likelihood that a person with an acute upper gastrointestinal bleeding (UGIB) will need to have medical intervention such as a blood transfusion or endoscopic intervention.[1] The tool may be able to identify people who do not need to be admitted to hospital after a UGIB

Question 18

Symptoms of significant hemorrhage

Answer 18

postural hypotension, dizziness, syncope, palpitations, tachypnea, altered mental state (anxious, aggressive, drowsy, confused, or unconscious, these are stepwise from class 1 to class 4) and cold peripheries are all indicative of significant haemorrhage

Question 19

How long should you be nil by mouth before OGD?

Answer 19

At least 4 hours

Question 20

What is blood loss volume classified into?

Answer 20

4 classes
Class 1 <15% (750ml)
Class 4 >40% (greater than 2000 ml)

Question 21

Lying standing blood pressure in hemorrhage

Answer 21

Measurement of lying and sitting/standing blood pressures can be very helpful, since a postural drop in blood pressure is an earlier indicator of significant blood loss, and occurs before the onset of supine hypotension

Question 22

Falsely reassuring clinical observations in hemorrhage

Answer 22

• Be aware that patients taking rate controlling medications, particularly beta blockers, may not mount a tachycardic response to blood loss.
• You should also note that reassuring blood pressure readings may in fact be abnormal for those with undiagnosed or poorly controlled hypertension.

Question 23

Steps to take during major hemorrhage

Answer 23

• Seek senior help early
• Resuscitate and stabilize the patient (A-C)
• IV access (two large bore 16 gauge cannulas)
• Investigations (FBC, U/Es, LFTs, Clotting profile, group and save (consider cross matching 4-6 units of bloods if there is significant bleeding), lactate). It is also important to arrange a chest radiograph and ECG in high risk patients, for example those with a known cardiovascular or respiratory comorbidity.
• IV fluids (Ideally blood, until that’s available give saline or Hartman’s)

Question 24

Hemoglobin in major hemorrhage

Answer 24

The haemoglobin level on the initial full blood count can be misleading as an indicator of the severity of the bleed. Since haemoglobin is expressed as a concentration, its value will only begin to fall when the circulating volume is restored.

Question 25

Administration of platelets and clotting factors in GI bleed

Answer 25

• Coagulopathy and/or platelet dysfunction are common in patients with upper gastrointestinal bleeding.
• Part of the initial management is to correct coagulopathy and reversible factors
• Offer platelet transfusion to patients with active bleeding who have a platelet count of less than 50 × 109/L
• Offer fresh frozen plasma to patients who have either: A fibrinogen level of less than 1.5 g/L, or Prothrombin time (INR) or activated thromboplastin time greater than 1.5 times normal
• Offer cryoprecipitate if the fibrinogen remains less than 1.5 g/L despite fresh frozen plasma
• Offer prothrombin complex concentrate to patients with active bleeding who are taking warfarin

Question 26

What is used to calculate GI beed patient’s risk of needing an intervention?

Answer 26

Calculate the patient’s risk of needing an intervention with the Blatchford score
NICE guidelines recommend calculation of:
Blatchford score at initial assessment, and
Full Rockall score after endoscopy.

Question 27

Risk factors that increase upper GI bleed mortality

Answer 27

• Age: Death from upper gastrointestinal bleeding is rare under the age of 50 years, but increases thereafter, so that the mortality rate at the age of 90 years is 30%
• Shock: The risk progressively increases as the heart rate rises and blood pressure subsequently falls
• Comorbidity: The risk of dying is greatly increased if the patient also has a chronic medical condition, and is highest in those with advanced liver or renal failure, or those with metastatic cancer
• Findings at endoscopy: The last constituent of the Rockall score are the findings at endoscopy.

Question 28

Timing of Endoscopy in upper GI bleeds

Answer 28

• The timing of endoscopy depends on the severity of the bleed. Endoscopy can be performed either as an urgent or a semi-elective procedure, depending upon the clinical circumstances.
• For high risk, haemodynamically unstable patients with severe upper gastrointestinal bleeding, you should arrange an endoscopy to be performed immediately after adequate resuscitation. Ideally this should be in a safe, specialised environment such as an operating theatre
• All other stable, low risk patients should have endoscopy within 24 hours of admission

Question 29

Purpose of endoscopy in upper GI bleed

Answer 29

Endoscopy in acute upper gastrointestinal bleeding is used to:

• Determine the cause of the bleeding
• Treat active bleeding lesions, and
• Stratify the risk of rebleeding (ie using the Rockall score)

Question 30

Rate of rebleeding in upper GI bleeds following endoscopy repair

Answer 30

Up to 20% of patients

Question 31

What is tranexamic acid and its use in gastrointestinal bleeding

Answer 31

Tranexamic acid is a fibrinolytic inhibitor that may help to reduce rebleeding by reducing clot breakdown. It is no longer recommended for use in gastrointestinal bleeding following the outcome of the HALT-IT trial which showed an increased risk of venous thromboembolic events and no reduction in mortality from gastrointestinal bleeding

Question 32

Drugs to start following upper GI bleed

Answer 32

If non variceal, start PPI therapy, with loading IV dose first few days