Upper GI Bleeding

Question 1

What percentage of upper GI bleeds are self-limiting with no in-hospital re-bleeding?

Answer 1

80%.

Question 2

What causes death in upper GI bleeding?

Answer 2

Complications, rarely exsanguination.

Question 3

What are the 4 main causes of upper GI bleeding?

Answer 3

Duodenal ulcers, gastric erosions, gastric ulcers and varices.

Question 4

Why do you need to take extra care when assessing severity of conditions with young people and diabetics?

Answer 4

Young people compensate then crash hard. Diabetics have poor autonomic response (may be in poorer state than they appear due to lack of change of vital signs).

Question 5

What are the 3 uses of an endoscope in an upper GI bleed?

Answer 5

1. Identify cause.
2. Therapeutic maneouvres.
3. Assess risk of rebleeding.

Question 6

What is the old risk score used to assess upper GI bleeding?

Answer 6

Rockall risk scoring system.

Question 7

What is the current risk score used to assess upper GI bleeding (the one that NHS tayside uses?

Answer 7

Blatchford score.

Question 8

What are the components of the Blatchford score?

Answer 8

Urea, haemoglobin, systolic BP, other markers (pulse, malaena, syncope, hepatic disease, cardiac failure).

Question 9

What are the 3 stigmata of recent haemorrhage of peptic ulcers?

Answer 9

Active bleeding/oozing, overlying clot, visible vessel.

Question 10

What are the 5 ways that an endoscope can achieve haemostasis when treating peptic ulcers?

Answer 10

1. Injection (adrenaline)
2. Heater probe coagulation
3. Combinations (dual therapy is best, special piece of equipment for this)
4. Clips (usually clip either side of vessel)
5. Hemospray

Question 11

How does injecting adrenaline around the ulcer help prevent bleeding?

Answer 11

It produces vasocontrictor effect which slows rate of blood flow into ulcer base and causes tamponade effect, thereby preventing fibrinolysins in blood reaching clot.

Question 12

What are the 2 downsides of hemospray?

Answer 12

Produces complicated wound to clean up late, makes mess which makes it harder to find where to give definitive treatment.

Question 13

What is given to suppress acid in peptic ulcer bleeding?

Answer 13

IV omeprazole.

Question 14

How many times can you do an endoscopy if a patients bleed restarts?

Answer 14

Only once more as they may deteriorate and be unfit for surgery.

Question 15

What are the risk factors for acute variceal bleeding?

Answer 15

> 12mmHg pressure, varices cover >25% of oesophageal lumen, presence of red signs, degree of liver failure (Childs A<b></b>

Question 16

What are the 2 main complications in variceal bleeding?

Answer 16

Sepsis (translocation of bacteria over gut wall), liver failure.

Question 17

What information in the patients history would make you suspect variceal bleeding?

Answer 17

Chronic alcohol excess, chronic viral hepatitis infection, metabolic or autoimmune liver disease, intra-abdominal sepsis/surgery.

Question 18

What information on examination would make you suspect variceal bleeding?

Answer 18

Stigmata of chronic liver disease.

Question 19

What are the 5 aims of management for variceal bleeding?

Answer 19

Resuscitation, haemostasis, prevent complications of bleeding, prevent deterioration of liver function, prevent early re-bleeding.

Question 20

Give some initial considerations for someone with variceal bleeding.

Answer 20

Coagulopathy (administer fresh frozen plasma/platelets/vit K), CVP monitoring, give parenteral vitamins, give broad spectrum antibiotics (prevent sepsis), they may have unexpected pathology e.g. bleeding ulcer, may have hypoglycaemia, replace potassium/magnesium/phosphates, watch out for withdrawal syndrome.

Question 21

What are the 5 ways haemostasis can be achieved in variceal bleeding?

Answer 21

1. Terlipressin (vasopressin analogue, reduced portal venous pressure).
2. Endoscopic variceal ligation (banding).
3. (Sclerotherapy) if oesophagus gets fibrotic due to too much banding.
4. Sengstaken-Blakemore balloon (stops blood flowing upward from stomach vessels).
5. Transjugular, intrahepatic portosystemic shunt (TIPS).

Question 22

Describe how TIPS is performed.

Answer 22

Access jugular vein, put wires into SVC and find renal veins. Wires puncture through renal vein through liver parenchyma into portal vein, balloon passed over and stented.

Question 23

What do you do if variceal bleeding stops after treatment?

Answer 23

Give propanolol and banding program.

Question 24

If bleed continues after banding, what should be done?

Answer 24

TIPS.

Question 25

After tips, what is the next step if liver function is poor and if it is good?

Answer 25

Poor - consider transplant.

Good - observe.