Upper GI Bleeding

Question 1

What are the three main things to look for in someone suspected of having an upper GI bleed?

Answer 1

1. Signs of CLD - clubbing, palmar erythema, spider naevi, gynaecomastia, testicular atrophy, anaemia, capital medusa)
2. PR (for malaena)
3. Signs of shock (cool, clammy, low BP, high HR, Cap refill >2, urine output <30ml/hr, GCS dropped)

Question 2

What is the most common cause of upper GI bleeding?

Answer 2

Peptic ulcer disease (40%)

Question 3

What are the other main causes of upper GI bleeding? (5)

Answer 3

Acute erosions/gastritis (20%)
Mallory-Weiss tear (10%)
Varices (5%)
Oesophagitis (5%)
Stomach/oesophageal cancer (<3%)

Question 4

What is the tool used to predict risk of re-bleeding in upper GI bleeds

Answer 4

Rockall score

Made up of firstly, age, co-morbidities, how much shock they were in, plus a endoscopic report on the bleedings, vessel and clot.

pre-endoscopy score > or equal to 3 = surgery
post endoscopy score >6 = surgery

Question 5

In upper GI bleed patients, what percentage of re-bleeders die?

Answer 5

40%

Question 6

Portal HTN causes dilation of veins at sites of porto-systemic anastamosis. Where are these veins?

Answer 6

Left gastric, inferior oesophageal, rectal veins

Question 7

What percentage with portal HTN will bleed from varices?

Answer 7

30-40%

Question 8

What percentage of those with oesophageal varices die from them?

Answer 8

25%

Question 9

What are the pre-hepatic (1), hepatic (3) and post-hepatic (3) causes of portal HTN?

Answer 9

pre: portal vein thrombosis
hepatic: Cirrhosis (80% of UK), schistosomiasis (commonest worldwide), sarcoidosis
post: Budd-Chiari (occlusion of hepatic veins), RHF, constrict pericarditis

Question 10

What are the 2 options for primary upper GI bleeding prevention?

Answer 10

Beta blocker

endoscopic banding

Question 11

What are the 3 options for secondary upper GI bleeding prevention?

Answer 11

Beta blocker
repeat endoscopic banding
Transjugular intra-hepatic portosystemic shunting (TIPSS)

Question 12

In an acute upper GI bleed, what fluid do you choose once you have used 1L of crystalloid, and it has had no haemodynamic affect?

Answer 12

O negative blood or specific blood if already cross-matched

Question 13

What two drugs do you give in an acute upper GI bleed?

Answer 13

IV Terlipressin (splanchnic vasopressor)

Prophylactic ABx: e.g. ciprofloxacin

Question 14

What are the three main options for correcting coagulopathy?

Answer 14

Vit K
Fresh frozen plasma
Platelets

Question 15

What is the management for a GI bleed patient post-endoscopy? (5)

Answer 15

Omeprazole
NBM for 24hrs
Daily bloods: FBC, U+E, LFT, Clotting
H. Pylori testing
Stop NSAID's, steroids, etc

Question 16

What complication can occur when using normal saline in uncompensated liver disease? What alternative can be used?

Answer 16

Worsens ascites and peripheral oedema

Use 5% dextrose for maintenance and whole blood/salt-poor albumin for resus