Upper GI bleeding

Question 1

How is an upper GI bleed treated?

Answer 1

assess the severity of the haemorrhage
‘The 100 Rule’: poor prognostic group
systolic BP < 100mmHg
pulse > 100/min
Hb < 100 g/l
age > 60
comorbid disease
postural drop in blood pressure
diabetics have poor autonomic response
beta-blockers
RESUSCITATE then facilitate prompt endoscopy

Question 2

How mny litres of blood does a normal adult have?

Answer 2

5l

Question 3

What type of endoscopy is used to investigate Upper GI bleeding?

Answer 3

oesophago-gastroduodenoscopy (OGD)

Question 4

What does the Rockall risk scoring system take into account?

Answer 4

Mortality risk based on:
age
pulse
SBP
co-morbidity
diagnosis
stigmata

Question 5

What are the two main causes of Upper GI bleeding?

Answer 5

Bleeding peptic ulcers

Variceal bleeding

Question 6

What is the treatment of upper GI bleeding?

Answer 6

Endoscopic treatment (high risk ulcers)
Acid suppression (PPI infusions)
Surgery
(H. pylori eradication - secondary prevention)

Question 7

What is the endoscopic treatment of peptic ulcers?

Answer 7

Injection (adrenaline 1:10000)
Heater probe coagulation
Combinations
Clips
Haemospray

Combination therapy is the best – injection plus clips

Question 8

How does haemospray work?

Answer 8

Dessicates a deep wound and produces immediate clotting – pour it on people when their leg falls off

Question 9

What is the role of IV omeprazole?

Answer 9

Reduces re bleeding and mortality and the need for surgery

Question 10

What group of people are more suceptible to varices?

Answer 10

liver disease

Question 11

What are the risk factors for varices?

Answer 11

• portal pressure > 12mmHg
• varices > 25% oesophageal lumen
• presence of red signs
• degree of liver failure (Child’s A<b></b>

Question 12

What things increase the risk of bleeding?

Answer 12

Red spots on varicies are a sign of mucosal weakening – elevated risk of bleeding
Worse the liver disease = greated risk of bleeding
Cirrohsis will cause bleeding
Cirrohsis with GI bleed causes translocation of bacteria across the gut wall which causes bleeding

Question 13

How do varices occur?

Answer 13

Input from the portal vein increases so pressure in all of the draining vessels rises
Drainage from the gastroesophageal junction is through the portal vein
Vessels start to distend

Question 14

What is the history and clincial signs of variceal bleeding?

Answer 14

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

Clinically: stigmata of chronic liver disease

Question 15

What is Encephalopathy?

Answer 15

elevation of ammonia in the blood has neurotoxic effects in the brain – causes liver flat

Question 16

What is the management of Variceal bleeding?

Answer 16

Resusciation
Haemostasis
Prevent complications of bleeding
Prevent deterioration of liver function
Prevent early re-bleeding

Question 17

What are the ways of treating variceal bleeding?

Answer 17

coagulopathy (FFP/platelets/vitamin K)
CVP monitoring (portal pressure vs CVP)
parenteral vitamins - cardemex
antibiotics - to avoid sepsis
unexpected pathology e.g. perforated D.U.
hypoglycaemia - severe complication in liver disease
replace K+, Mg2+ and PO42-
delirium tremens (perhaps later)

Question 18

How can homeostasis be achieved?

Answer 18

Terlipressin (vasopressin analogue- consriction of blood flow to the gut)
Endoscopic variceal ligation (banding)
Sclerotherapy
Sengstaken-Blakemore balloon - stops blood flow
TIPS - Transjugular, intrahepatic, portosystemic shunt

Question 19

Describe TIPS?

Answer 19

Puts wire into the renal vein -> hepatic paracheyma -> portal vein

Question 20

Describe Terlipressin?

Answer 20

vasopressin prodrug
ease of use: bolus 1-2mg 4 hrly
predominantly splanchnic vasoconstrictor
beneficial effect on renal perfusion