Upper GI Bleeds

Question 1

Good GI bleed history.

Answer 1

What do they mean by passing blood? Haematemesis? Coffee ground vomit? Melaena? Fresh PR bleeding?

Ask about past GI bleeds/dyspepsia/liver disease/oesophageal varices/dysphagia/vomiting/weight loss.

Drug history

Alcohol

Cardiovascular disease, respiratory, hepatic or renal impairment.

Malignancy

Look for signs of chronic liver disease.

Do PR to check for melaena.

Question 2

Does melaena have anything do to with upper GI bleed?

Answer 2

Yes, haematemesis, coffee ground vomit and melaena all indicated upper GI bleed.

Fresh PR bleed is more indicative of distal GI bleed.

Question 3

Common causes of upper GI bleed.

Answer 3

Oesophageal varices (IMPORTANT TO RULE OUT)

Peptic ulcers

Mallory-Weiss tear

Gastritis

Drugs like NSAIDs, aspirin, steroids, thrombolytics and anticoagulants

Oesophagitis

Duodenitis

Malignancy

Question 4

Rare causes of upper GI bleed.

Answer 4

Bleeding disorders

Portal hypertensive gastropathy

Aorto-enteric fistula

Angiodysplasia

Haemobilia

Dieulafoy lesion

Meckel’s diverticulum

Peutz-Jegher’s syndrome

Osler-Weber-Rendu syndrome

Question 5

Examinations of Upper GI bleed.

Answer 5

Look for signs of chronic liver disease

PR for melaena

Check if peripheries are cool/clammy

Capillary refill time >2s

Urine output

GCS to assess for decompensated liver disease or encephalopathy

Tachycardia

Systolic BP <100 mmHg

Calculate the Rockall score

Question 6

What two assessment scores should be done in GI bleedings?

Answer 6

ROCKALL score

Blatchford score

Question 7

What is the Rockall score used for?

Answer 7

It is a simple score based on bedside parameters.

It predicts the risk of death and rebleeding from an upper GI bleed.

It is split into a pre-endoscopy and a post-endoscopy score.

Question 8

Explain the Rockall score.

Answer 8

Question 9

What is the Glasgow Blatchford Score used for?

Answer 9

It predicts the need for intervention such as blood transfuion or therapeutic endoscopy.

It requires the results of some blood tests to be useful.

It is most useful in deciding if a patient needs admitting to hospital or not.

If GBS = 0 admission can be avoided.

Question 10

Glasgow-Blatchford score.

Answer 10

Question 11

Investigations of Upper GI bleed.

Answer 11

FBC to check Hb and platelet count (low platelet might suggest chronic liver disease)

U&Es - raised urea is indicative of upper GI bleed

Clotting

Group and Save (cross match if haemodynamically unstable) you may need to give blood transfusions.

LFTs

Venous blood gas (quick way to get a haemoglobin result)

Endoscopy

Question 12

Acute management of upper GI bleed.

Answer 12

1 - Protect airways and give high flow O2

2 - Insert 2 large-bore IV cannulae and take blood for FBC, U&Es, LFT, clotting and crossmatch.

3 - Give IV fluids to restore intravascular volume while waiting for cross-matched blood. If still deteriorating despite fluids give group O Rh-ve blood. Avoid saline if cirrhotic or varices.

4 - Insert a urinar catheter and monitor hourly urine output

5 - Organise a CXR, ECG and check ABGs

6 - Consider a CVP line to monitor and guide fluid replacement

7 - Transfuse blood if significant Hb drop (<70g/L)

8 - If suspicion of varcies give terlipressin IV 1-2mg/6h for 3 days or less. Initate broad-spectrum IV antibiotics to cover.

9 - Mointor pulse, BP, CVP at least hourly until stable.

10 - Arrange urgent endoscopy

11 - If endoscopic control fails, surgery or emergency mesenteric angiography/embolisation may be needed. Sengstaken-Blakemore tube can compress varices.

Question 13

Further management of upper GI bleed.

Answer 13

Assess risk of rebleeding

Re-examine after 4 hours and consider the need for FFp if >4 units has been transfused.

Hourly pulse, BP, CVP, urine output shuold be checked

Transfuse to keep Hb >70g/l

Check FBC, U&Es, LFTs and clotting daily

Keep nil by mouth if at high rebleed risk.

Question 14

Management of variceal bleeding (according to WB)

Answer 14

Gain IV access.

Fluid resus if haemodynamically unstable.

IV terlipressin if no IHD or peripheral vascular disease.

IV antibiotics

Refer urgently to the GI team for Upper GI endoscopy.

Question 15

Definitive treatment of variceal bleeding.

Answer 15

Mechanical obstruction to the flow of blod through the varcies.

Can be done via endoscopic banding.

If this is not enough a Lintor or Sengstaken tube may be required as a temporary measure.

TIPSS (trans-jugular intrahepatic porto-systemic shunt) can be done as well.

Question 16

Management of non-variceal bleeding (according to WB).

Answer 16

Gain IV access. Fluid resus if haemodynamically unstable and then blood if still is.

PPi after endoscopy might be indicated.

Radiological embolisation or surgery if nothing helps.

Question 17

Management of peptic ulcer bleeds based on endoscopic findings if they are high risk.

Answer 17

Aka active bleeding, adherent clot or non-bleeding visible vessels.

Achieve endoscopic haemostasis with clips, cautery or adrenaline.

Admit to monitored bed and start PPi.

If they are haemodynamically stable start oral intake of clear liquids 6h after endoscopy.

Question 18

Management of peptic ulcer bleeds based on endoscopic findings if they are low risk.

Answer 18

Aka flat, pigmented spot or clean base.

There is no need for endoscopic haemostasis. Consider early discharge.

Give oral PPi.

Regular diet 6h after endoscopy if stable.

Question 19

Causes of portal HTN.

Answer 19

Pre-hepatic - thrombosis of portal or splenic vein.

Intrahepatic - Cirrhosis, schistosomiasis, sarcoid, myeloproliferative diseases, congenital hepatic fibrosis.

Post-hepatic - Budd-Chiari, Right heart failure, Constrictive pericarditis, veno-occlusive disease.

Question 20

Risk factors for variceal bleeds in portal HTN:

Answer 20

Increased portal pressure

Variceal size

Endoscopic features of the variceal wall and advanced liver disease.

Question 21

Management of gastro-oesophageal varices.

Answer 21

Endoscopic banding or sclerotherapy.

Prophylaxis of b-blokade or propanolol or repeat endoscopic banding.

TIPSS if resistant varices.