Upper GI haemorrhage

Question 1

What are the causes of acute upper GI haemorrhage?

Answer 1

Oesophagus:
  - Oesophageal varices (10%)
  - Mallory-Weiss tear (10%)
Stomach:
  - Gastric ulcer (25%)
  - Erosive haemorrhagic gastritis (10%)
Duodenum:
  - Duodenal ulcer (25%)
  - Erosive duodenitis (5%)
Any:
  - Tumours

Question 2

Immediate management/resuscitation of upper GI haemorrhage?

Answer 2

• Large-bore IV lines with crystalloid & colloid fluid resuscitation, followed by whole blodd
• Urinary catheter
• Bloods: FBC, U&E, creatinine, INR, LFTs, cross-match

Question 3

In which cause of upper GI haemorrhage do you NOT give sodium-containing fluids, and why? Which fluids can you give them?

Answer 3

Patients with oesophageal varices secondary to liver disease
Sodium-containing crystalloids may lead to a deterioration of liver function and ascites
These patients should be resuscitated with 5% dextrose, FFPs to replenish clotting factors, Octreotide to lower portal pressure

Question 4

What is the diagnostic procedure for an upper GI bleed? How can you help prep the patient for this procedure?

Answer 4

Endoscopy

Can empty stomach with nasogastric tube (not routinely indicated)

Question 5

When is an urgent endoscopy indicated?

Answer 5

• Oesophageal varices are suspected

- Signs of continued haemorrhage

Question 6

When should high-risk patients get an endoscope done?

Answer 6

Once they are stabilised

Question 7

When should non-high-risk patients get an endoscope done?

Answer 7

12-24 hours after admission, when clinically stable and resuscitated

Question 8

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IA

Answer 8

Spurting blood (visible vessel)

Question 9

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IB

Answer 9

Oozing blood (non-visible vessel)

Question 10

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IIA

Answer 10

Non-bleeding visible vessel

Question 11

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IIB

Answer 11

Adherent clot

Question 12

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IIC

Answer 12

Pigmented spot

Question 13

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade III

Answer 13

Clean ulcer base

Question 14

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: High risk grades?

Answer 14

IA, IB, IIA, IIB

Question 15

Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Low risk grades?

Answer 15

IIC, III

Question 16

When is angiography indicated in an upper GI bleed?

Answer 16

• When patient continues to bleed and endoscopy fails to find bleeding site
• When endoscopic methods fail to control bleeding, and patient is poor candidate for surgery: NB, must be non-variceal cause

Question 17

What Rockall score indicates an increased risk of rebleeding and death following an upper GI bleed?

Answer 17

> 2

Question 18

What are the categories incorporated into the Rockall score?

Answer 18

Age
Haemodynamic status: BP + HR
Co-morbidities
Endoscopic diagnosis
Stigmata of recent haemorrhage

Question 19

Medical treatment of upper GI bleed?

Answer 19

IV PPI’s (change to PO later) - this is to raise the intragastric pH >6 and prevent clot lysis
H. pylori eradication therapy (after stabilised)

Question 20

Which patients are at risk for rebleeding?

Answer 20

• > 60 y/o
• Shock on admission
• Endoscopic stigmata of recent bleeding (Forrest high risk group)
• Large ulcers (>2cm)
• Ulcers in lesser curve of stomach and posterior duodenal bulb

Question 21

When are patients at highest risk of rebleeding?

Answer 21

First 48 hours after haemorrhage

Question 22

Endoscopic methods for control of upper GI bleeding?

Answer 22

• Diluted (1:10,000) adrenalin tamponade injection into tissue surrounding bleeding vessel
• Bipolar thermal coagulation
• Metal clip

Question 23

Indications for surgery for an upper GI bleed?

Answer 23

• Exsanguinating haemorrhage
• Associated perforation
• Failed endoscopic therapy of actively bleeding, shocked patient
• Recurrent bleeding after endoscopic therapy
• At risk for rebleeding when endoscopy not available