Upper GI bleeds

Question 1

Describe two obvious characteristics of upper GI bleeding?

Answer 1

• Haematemesis
  
  • Vomiting blood: red or coffee ground
• Melaena
  
  • Black bowel motions

Question 2

Causes of upper GI bleeding?

From most to least common

Answer 2

• Peptic ulcer
• Gastric erosions
• Oesophagitis
• Mallory-Weiss tear (retching)
• Varices

Question 3

Drug causes of upper GI bleeding?

Answer 3

• NSAIDs
• Aspirin
• Steroids
• Thrombolytics
• Anticoagulants

SATAN*

Question 4

Describe a risk score for upper GI bleeds?

Answer 4

Rockall risk-score

Question 5

What invesitgation should be performed urgently for someone with upper GI bleeding?

Answer 5

Endoscopy

Question 6

Describe the management of high-risk peptic ulcer bleeds based on endoscopic findings?

Answer 6

• Active bleeding, adherent clot or non-bleeding visible vessel
• Achieve endoscopic haemostasis
  
  • 2 of:
    
    • Clips
    • Cautery
    • Adrenaline
• Start PPI
• If haemodynamically stable: Oral intake of clear liquids 6h post endoscopy
• Treat H. pylori if positive

Question 7

Describe the management of low-risk peptic ulcer bleeds based on endoscopic findings?

Answer 7

• Flat, pigmented spot or clean base
• No need for endoscopic haemostasis
• Consider early discharge
• Give oral PPI
• Regular diet 6h post endoscopy
• Treat H pylori if positive

Question 8

Most common cause of upper GI bleeds?

Answer 8

Peptic ulcer disease

Question 9

Important aspects of a history of someone with upper GI bleeding?

Answer 9

• Previous bleeds
• Dyspepsia, known ulcers
• Liver disease or oesophageal varices
• Dysphagia, weight loss
• Drugs
• Co-morbidities

Question 10

Management of upper GI bleeding?

Answer 10

Question 11

What do haematemsis and coffee ground vomiting indicate respectively?

Answer 11

• Haematemesis
  
  • Red with closts
  • Bleeding is rapid and profuse
• Coffee ground vomiting
  
  • Black
  • Bleeding is less profuse

Question 12

Describe malaena?

Answer 12

• Passage of black, tarry stools
• Usually from upper GI bleeding
  
  • Also haemorrhage of right colon
• Colour and smell are due to action of digestive enzymes and bacteria on Hb

Question 14

Describe the steps involved in the emergency management of upper GI bleeding?

Non-variceal bleeding **

Answer 14

• IV access
• Clinical assessment
• Basic investigations
• Resuscitation
• Oxygen
• Endoscopy
• Monitoring
• Surgery
• Eradication

Question 15

Describe the initial clinical assessment of someone with upper GI bleeding

Answer 15

• Define circulatory status
  
  • Severe bleeding causes tachycardia, hypotension, oligiuria
• Seek evidence of liver disease
  
  • Decompensated cirrhosis: jaundice, hepatosplenomegaly, ascites
• Identify comorbidity
  
  • CV, respiratory or renal disease can be worsened by acute bleeding
• Glasgow blatchford score

Question 16

Describe the interpretation of a Glasgow Blatchford Score?

Answer 16

• Score of 2 or less: good prognosis
• Increasing scores thereafter = worse prognosis

Question 17

What basic investigations should be performed for someone with acute upper GI bleeding?

Answer 17

• FBC
  
  • Anaemia
  • May be normal after sudden bleeding until haemodilution occurs
• U&Es
  
  • Evidence of renal failure
  • Elevated urea with normal creatinine implies severe bleeding
• LFTs, PT, Cross-match 2 units of blood

Question 18

Describe the resuscitation of someone with acute upper GI bleeding?

Answer 18

• IV crystalloid fluids to raise BP
  
  • Saline
• Should be transfused when patient is actively bleeding with low BP and tachycardia

Question 19

Describe the endscopy for upper GI bleeding?

Answer 19

• Within 24 hours after resuscitation
• Can perform treatments:
  
  • Heater probe
  • Endoscopic clips + adrenaline injection
• Patients bleeding from varices:
  
  • Band ligation
  • TIPSS
• PPI should not be given before endoscopy as it can mask the site of bleeding

Question 20

Describe eradication therapy for those who have had an upper GI bleed from ulcers?

Answer 20

• Avoid NSAIDs
• H. pylori positive patients receive eradication
  
  • Confirmed by:
    
    • Urea breath test
    • Faecal antigen testing

Question 21

Name a specific treatment for someone with GI bleeding and cirrhosis

Answer 21

• Broad spectrum antibiotics due to sepsis risk
  
  • Oral Ciprofloxcin
  • or IV cephalosporin

Question 22

Describe the different drugs used in eradication therapy?

Answer 22

• Omeprazole
• Amoxicillin
• Metronidazole

Question 23

What blood test allows you to differentiate between an upper and lower GI bleed?

Answer 23

• U&Es
  
  • Elevated urea
  • Normal creatinine