Upper GI bleeding

Question 1

Is the majority of upper gi bleeding self limiting or not?

Answer 1

80% is self limiting with no in hospital re bleeding

Question 2

What is death usually due to in upper GI bleed patients?

Answer 2

Complications such as heart attack or aspiration pneuonia

Question 3

List some causes for upper GI bleeding

Answer 3

Duodenal ulcer
Gastric ulcer
Gastric erosions
Varices
Mallory-weiss tear
Oesophagitis
Erosive duodenitis
Neoplasm
Stomal ulcer
Oesophageal ulcer
Miscellaneous

Question 4

How does an upper GI bleed present?

Answer 4

Haematemesis
Malaena
Hypotension
Tachycardia
Collapse

Question 5

What is a risk triage for upper GI bleeds?

What scoring systems exist?

Answer 5

A mechanism to identify patients who can be safely discharged and those that require prompt and robust emergency care.
Rockall and Blatchford scoring systems exist

Question 6

What is the 100 rule?

What is the immediate treatment for patients in this category?

Answer 6

A rule to identify those in a poor prognostic group.
Systolic BP :  100
Hb < 100 g/l
age > 60
co-morbid disease
postural drop in blood pressure

Resuscitate the patient then prompt endoscopy

Question 7

Why is the Rockall score not useful in A and E admissions?

Answer 7

Because you require an endoscopy result

Question 8

When are PPIs given?

Answer 8

In a massive GI bleed i.e. Patients with overt sign of a GI bleed with hypotension

Question 9

Why are PPIs given?

What is the dosage?

Answer 9

If the pH in the stomach is less than four, any platelet plugs that are made are destroyed straight away. PPIs raise the pH so a platelet plug can form.
Dosage: 80mg bolus then 8mg/hour for 24 hours
It is usually only given IV if endoscopic therapy is given, if not then high dose oral.

Question 10

What is the treatment before and during endoscopy?

Answer 10

Prophylactic antibiotics
For active bleeding or oozing:
Adrenaline to vasoconstrict and stop the bleeding
Heater probe coagulation

Question 11

What is the treatment post endoscopy?

Answer 11

PPIs if not already started

Start eradication therapy for H pylori if DU

Question 12

What actions are carried out on a rebleed?

Answer 12

Resuscitate
Consider a second look endoscopy
Consider surgery
Consider interventional radiology

Question 13

What percentage of cirrhotics with varices will bleed in <2 years?

Answer 13

19-40 %

Question 14

What are the risk factors for a variceal bleed?

Answer 14

Portal pressure > 12 mmHg
Varices > 25% of oesophageal lumen
Presence of red signs
Degree of liver failure (childs A<b><C)</b>

Question 15

What are signs of a risk of variceal bleeding?

Answer 15

Spider naevi
Palmar erythema
Encephalopathy
Ascites
Leuconychia

Question 16

What is terlipressin?

Which patients should it be considered in?

Answer 16

A vasopressin which lowers portal hypertension.
It should be considered in patients with known chronic liver disease, previous variceal bleed or stigmata of chronic liver disease on examination, who are suspected of a variceal bleed.

Question 17

What procedure is used to stop a variceal bleed?

Answer 17

Endoscopic variceal ligation

Question 18

What is the initial treatment for a patient with a variceal bleed?

Answer 18

Resuscitation, antibiotics (usually septrin), terlipressin, early oesophagogastroduodenoscopy, endoscopic variceal ligation

Question 19

What is the treatment if a patients variceal bleed stops after initial treatment?

Answer 19

Propranolol and a banding programme

Question 20

What is the treatment if a patients bleeding doesn’t stop after initial treatment?

Answer 20

Endoscopic variceal ligation or S-B tube
If the bleed continues, TIPSS
If hepatic function is good, observe the patient.
If hepatic function is poor, consider transplant.

Question 21

What is TIPSS?

When should it be used?

Answer 21

Transjugular intrahepatic Portosystemic shunt
There is most evidence to support its use in chronic bleeding.
However its use is accepted in an acute situation when it is not possible to stop the bleeding endoscopically.