Upper GI haemorrhage

Question 1

Incidence of differing causes of upper GI bleeds

Answer 1

Gastric ulcer (25%)
Duodenal ulcer (25%)
Oesophageal varices (10%)
Mallory-Weiss tear (10%)
Erosive haemorrhagic gastritis (10%)
Erosive duodenitis (5%)
Other (tumour, vascular malformations, oesophagitis/ulcer)
NB tailor history to these causes

Question 2

How does the management differ for oesophageal varices as opposed to other causes of bleeding

Answer 2

Do not give sodium containing crystalloids (rather whole blood, 5% dextrose, FFP and Octreotide) as can lead to deterioration in LF and ascites

Question 3

Frontline investigation in upper GI bleed

Answer 3

endoscopy

Question 4

How do we classify bleeding peptic ulcers endoscopically

Answer 4

Forrest classification
High risk
lA spurting blood (visible vessel)
lB ooze blood (non-visible vessel)
llA non bleeding visible vessel
llB adherent clot
Low risk
IIC pigmented spot
lll clean ulcer base

Question 5

How do we risk stratify upper GI bleeds

Answer 5

Rockall risk score (>2 = high risk)

[age, HR, BP, endoscopy, co-morbidities, forrest]

Question 6

What is the aim of medical management of a bleeding peptic ulcer

Answer 6

Increase gastric pH (>6) - PPIs
Blood as needed
[H pylori irradication]

Question 7

Patients at risk for rebleeding in PUD

Answer 7

· Age over 60 years
· shock on admission
· endoscopic stigmata of recent bleeding (spurting vessel, visible vessel and fresh clot in base of ulcer)
· large ulcers (>2cm)
· lesser curve gastric and posterior duodenal bulb ulcers.

Question 8

Endoscopic control of peptic bleed

Answer 8

Adrenalin (1:10000)

Bipolar thermal coagulation

Question 9

What to do in patients who are unfit for surgery and endoscopy that has failed (PUD)

Answer 9

Transcatheter arterial embolisation

Question 10

Indications for surgery in peptic bleed

Answer 10

· Exsanguinating haemorrhage
· Associated perforation
· Failed endoscopic therapy of active bleeding in shocked patients
· Recurrent bleeding after endoscopic therapy
· Patients at risk for rebleeding where endoscopic therapy is not available