Upper GI Bleeding

Question 1

What does upper GI bleeding present with? [3]

Answer 1

1. haematemesis (vomiting blood)
2. coffee ground vomiting
3. melaena (production of dark sticky faeces containing partly digested blood)

Question 2

What are the potential causes of an upper GI bleed? [7]

Answer 2

1. peptic ulcer
2. oesophagitis
3. gastritis
4. duodenitis
5. varices
6. malignancy
7. mallory-weiss syndrome

Question 3

How should you initially assess and manage a patient with GI bleeding? [6]

Answer 3

1. resuscitate
   
   • check pulse & BP
   • IV access for fluids/bloods
     
     • check blood - Hb & urea
   • lie flat & give oxygen
2. risk assessment:
   
   • high risk → emergency endoscopy
   • moderate risk → admit & next day endoscopy
   • low risk → possible out-patient management

Question 4

When should you do an endoscopy?

1. for most patients? [1]
2. very low risk patients (GBS≤1)? [1]
3. very high risk patients (haemodynamic instability or severe ongoing bleeding)? [1]

Answer 4

1. endoscope within 24 hrs (even at weekend)
2. can be discharged for out-patient endoscopy
3. emergency endoscopy

Question 5

What should you do if a patient with a GI bleed is on the following medications:

1. aspirin? [2]
2. NSAIDs? [1]
3. clopidogrel/warfarin? [1]

Answer 5

1. continue low dose aspirin once haemostasis is achieved + add PPI
2. stop NSAIDs
3. discuss risk/benefits with cardiologist/stroke team

Question 6

Variceal bleeding:

1. causes? [2]
2. resuscitation? [3]
3. how to diagnose? [1]
4. primary prophylaxis? [2]
5. therapy? [3]
6. what to do if the bleeding is uncontrolled? [2]

Answer 6

1. causes:
   
   • increased hepatic resistance (cirrhosis)
   • increased portal inflow
2. resuscitation:
   
   • restore circulating volume
   • transfuse once Hb<7-8g/dL
   • consider airway protection
3. diagnose by endoscopy
4. primary prophylaxis:
   
   • beta-blockers or
   • banding
5. therapy:
   
   • antibiotics (give early)
   • vasopressors - terlipressin (give early)
   • endoscopic banding treatment - first line for oesophageal variceal banding
6. uncontrolled bleeding:
   
   • use Sengstaken tube (TIPS)
   • balloon tamponade (temporary salvage)