Upper GI Bleeding

Question 1

How does upper GI bleeding present?

Answer 1

Haematemesis
Coffee ground vomiting
Melaena
- black, runny stools

Question 2

What constitutes the upper GI?

Answer 2

Mouth
Oesphagus
Stomach
Duodenum

Question 3

List some of the causes of upper GI bleeding.

Answer 3

Peptic ulcer
Oesophagitis 
Gastritis
Duodenitis
Varices
Malignancy
Mallory- Weiss tear
- a tear in the mucous membrane where the gastro-oesophageal membrane
Other

Question 4

Name some causes of peptic ulceration.

Answer 4

Hypergastinaemia
H.Pylori
NSAIDs

Question 5

How is upper GI bleeding managed?

Answer 5

Resuscitate if required
- venflons and fluid
Risk assessment and timing of endoscopy
Drug therapy and transfusion

Question 6

How and when does a patient with upper GI bleeding need resuscitation?

Answer 6

If the BP is low and the heart rate is high
IV access gained for fluids and bloods
Check Hb and urea
Lie them flat and given them oxygen

Question 7

What are the risk assessment categories and related timings of endoscopy?

Answer 7

High risk
- emergency endoscopy 
Moderate risk 
- admit and next day endoscopy (most patients)
Low risk
- out patient management

Question 8

What is the Rockall Score?

Answer 8

Predicts the mortality for upper GI bleeding

Question 9

What components are assessed when predicting mortality with the Rockall score?

Answer 9

Age
Shock
- pulse
- systolic bp
Co-morbidities

Question 10

What admission risk markers are assessed with the Glasgow Blatchford Score (GBS)?

Answer 10

Blood urea 
Haemoglobin 
Systolic blood pressure 
Pulse
Presentation with melaena 
Presentation with syncope 
Hepatic disease
Cardiac failure

Question 11

When should the prognostic score be used?

Answer 11

Glasgow Blatchford Score used for initial assessment

Full Rockall score after endoscopy

Question 12

What are the stigmanta of bleeding?

Answer 12

High risk of rebleeding 
- active bloodclot 
- NBVV
Moderate risk of rebleeding 
- clot formation 
Low risk of rebleeding 
- dot
- clean base

Question 13

What endoscopic therapy can be used for treatment of upper GI bleeding?

Answer 13

Adrenaline injection to constrict the blood flow
Heater probe
Endoscopic clips to clip the open vessels shut
Thrombin injection to promote clotting
Laser (ablation - burn the open wounds shut)

Question 14

List the categories of treatment available for upper GI bleeding.

Answer 14

Endoscopic therapy 
Radiological embolisation (endovascular)
Emergency surgery (rarely needed)
Drug theapy
Blood transfusion

Question 15

Which drugs are useful in treatment of upper GI bleeding?

Answer 15

IV PPIs

- reduces rebleeding and mortality post-endoscopy

Question 16

What do you do if the patient is on antiplatelets or anticoagulants?

Answer 16

Aspirin
- continue low dose after bleeding once haemostasis is achieved (add PPI)
Stop NSAIDs
NOAC/warfarin
- discuss risk/benefit with CV team once haemostasis is achieved

Question 17

When are blood products used in upper GI bleeding?

Answer 17

Restrictive transfusion if Hb <7-8g/dL
Platelet transfusion is active bleeding and platelet count is <50x109/L
Fresh frozen plasma if INR >1.5
PT complex concentrate is on warfarin and they are actively bleeding

Question 18

What is the mortality rate of a ruptured variceal bleed?

Answer 18

30-40%

Question 19

How are unruptured variceals managed?

Answer 19

Endoscopic banding
or
Beta-blocker drugs (to reduce the portal pressure)
TIPS

Question 20

How is acute variceal bleeding managed?

Answer 20

Resuscitation
- restore circulating volume
- transfusion if Hb<7-8g/dL
- consider airway protection
Endoscopy for diagnosis
Therapy 
- antibiotics in the cirrhotic subset 
- vasopressors (terlipressin)
- endoscopic banding treatment

Question 21

What should you do in uncontrolled variceal bleeding?

Answer 21

Sengstaken tube
- tube inflated in the oesophagus to hold pressure on the bleeds
- balloon tamponade
TIPS
- transjugular intrahepatic portosystemic shunt
Surgical shunt/transection is TIPS fails

Question 22

In general, what is the optimal management of an upper GI bleed?

Answer 22

Resuscitate
Risk assess
Time endoscopy
Drug therapy and transfusion