Upper GIT Bleeds

Question 1

85 year old man brought to the ED from a nursing home reportedly having “vomited a large cupful of blood and then passed out for a while”
Had been in nursing home for rehabilitation following Sx for hip #
PHx: ulcer operation some 40 years ago, partial gastrectomy, known AAA for 10 years (followed up with interval U/S), known hepatitis from blood transfusion for stomach ulcer (has progressed to cirrhosis)
What medical problems in PHx might account for his current presentation?

Answer 1

AAA: can get aorto-enteric fistula causing haematemesis
Cirrhosis: possible variceal haemorrhage

Question 2

85 year old man brought to the ED from a nursing home reportedly having “vomited a large cupful of blood and then passed out for a while”
Had been in nursing home for rehabilitation following Sx for hip #
PHx: ulcer operation some 40 years ago, partial gastrectomy, known AAA for 10 years (followed up with interval U/S), known hepatitis from blood transfusion for stomach ulcer (has progressed to cirrhosis)
Rx: NSAID, warfarin (last INR not known)
O/E: BP 100/60 mmHg lying, 80/50 mmHg sitting, HR 100 (110 on sitting)
Ix: ECG shows RBBB
What do you do next?

Answer 2

Need for urgent resuscitation (give fluids until you can give blood)

Question 3

What does haematemesis suggest about the site of an upper GI bleed?

Answer 3

From a source proximal to ligament of Treitz

Question 4

What does malaena suggest about the site of an upper GI bleed?

Answer 4

Blood has undergone some digestive action; source is close to ileocaecal valve
Unformed malaena suggests active bleeding

Question 5

Is blood from the upper GI always passed per rectum as malaena?

Answer 5

No; torrential loss may result in passage of bright-red blood

Question 6

What is the usual underlying cause of death from acute upper GI bleed?

Answer 6

Associated with decompensation of co-existing medical conditions precipitated by the acute bleeding event

Question 7

What large arteries/veins are at risk of bleeding with a perforated peptic ulcer?

Answer 7

Gastroduodenal artery

Portal vein

Question 8

List 4 clinical “yardsticks” that may indicate bleeding is haemodynamically significant?

Answer 8

External evidence of blood loss >500 mL
Resting tachycardia >100 (beware: patients on B blockers may not exhibit a tachycardia!)
SBP less than or equal to 100 (BP of 110 may not be “normal” for elderly patients)
Orthostatic hypotension: HR increase of >20 and/or decrease in SBP >20 mmHg

Question 9

Patients who should be assessed as high-risk and triaged to a monitored setting +/- consider admission to ICU

Answer 9

Elderly
Clinical evidence of recurrent or ongoing bleeding
Significant bleed
Syncope
Co-existing illness (esp IHD)
Respiratory complications

Question 10

Mx of significant upper GI bleeding

Answer 10

1) Establish portal for transfusion (2 large bore 16/-18 gauge IV cannulas; ASAP, as BP decreases this will only become more difficult)
2) Obtain a supply of blood (crossmatch)
3) Early, urgent effort to make anatomical diagnosis
4) Early involvement of endoscopist, ICU, general surgeon
NB if source is bleeding ulcer, give IV PPI stat

Question 11

List 5 principles for restoration of normovolaemia

Answer 11

1) Rapid infusion of crystalloids
2) Transfusion of colloids (plasma substitutes)
3) Packed cells and/or whole blood
4) Consider CVP monitoring (requires central venous catheter; this is available in ICU)
5) Urinary output monitoring with IDC

Question 12

What are the 3 most common causes of upper GI bleeding?

Answer 12

Peptic ulcer disease
Oesophageal varices
Gastro-duodenal erosions

Question 13

List 8 other causes of upper GI bleeding

Answer 13

Mallory-Weiss tear
Angioectasias
Oesophagitis
Upper GI tumour
Gastropathy
Large hiatus hernia
Dieulafoy lesion
Aorto-enteric fistula

Question 14

Dieulafoy lesion

Answer 14

A medical condition characterized by a large tortuous arteriole in the stomach wall (submucosal) that erodes and bleeds

Question 15

Aspects of Hx in upper GI bleeding which may indicate the underlying cause of the bleed

Answer 15

EtOH (varices, peptic ulcer, Mallory-Weiss tear)
Known peptic ulcer (with or without surgery)
NSAIDs
Chronic liver disease
AAA
Anti-coagulant medications

Question 16

What is the usual course of action if disastrous bleeding persists?

Answer 16

Laparotomy

Question 17

How long does it take for an urgent endoscopy to be performed?

Answer 17

6-12/24

Question 18

List 6 options for non-operative endoscopic Mx of upper GI bleeding

Answer 18

Heat coagulation
Adrenaline injection
Clips for bleeding peptic ulcer or erosive gastritis
Variceal ligation
PPI infusion
Octreotide infusion for varices (angiographic embolisation)

Question 19

Octreotide

Answer 19

Somatostatin analogue

Question 20

What surgical options are available for the Mx of upper GI bleeding?

Answer 20

Laparotomy and under-running of bleeder

Partial gastrectomy

Question 21

How is risk stratification for patients with upper GI bleeding achieved?

Answer 21

Blatchford score (score ranges from 0-23; higher scores indicate higher risk)
Rockall score (score ranges from 0-11; high scores indicate higher risk)

Question 22

What factors are taken into account when calculating a patient’s Blatchford score?

Answer 22

SBP
BUN
Hb
HR
Malaena
Syncope
Hepatic disease
HF

Question 23

What factors are taken into account when calculating a patient’s Rockall score?

Answer 23

Age
Shock (HR, BP)
Coexisting illness (esp cardiac, renal, hepatic)
Endoscopic diagnosis
Endoscopic stigmata of recent haemorrhage

Question 24

Outline the principles of Mx of acute bleeding from a peptic ulcer, according to clinical status and endoscopic findings

Answer 24

AT PRESENTATION:

1) Assess haemodynamic status (HR, BP, orthostatic changes)
2) FBE, UEC, BUN, coags, crossmatch
3) Initiate resuscitation and O2
4) Consider NGT placement and aspiration
5) Consider IV PPI (80mg bolus + continuous infusion at 8mg/hr)
6) Early endoscopy (within 24 hours; consider IV dose of erythomycin 30-60 mins before endoscopy and perform risk stratification prior to procedure)

Question 25

How should a high-risk patient with an acute peptic ulcer bleed be further managed?

Answer 25

1) Perform endoscopic haemostasis
2) ICU or monitored bed admit
3) IV PPI (80mg bolus + continuous infusion at 8mg/hr) for 72 hours post-endoscopy
4) Initiate clear fluids 6 hours post-endoscopy if haemodynamically stable
5) Transition to oral PPI
6) H. pylori testing + treatment if positive

Question 26

How should a low-risk patient with an acute peptic ulcer bleed be further managed?

Answer 26

1) Do not perform endoscopic haemostasis
2) Consider early hospital discharge post-endoscopy if otherwise low clinical risk, safe home environment
3) Oral PPI
4) Initiate oral intake with regular diet 6 hours post-endoscopy if haemodynamically stable
5) H. pylori testing + treatment if positive

Question 27

What distinguishes a high-risk patient from a low-risk patient on endoscopy?

Answer 27

High-risk: active bleeding or non-bleeding visible vessels

Low-risk: flat, pigmented spot or clean base

Question 28

How are oesophageal varices treated?

Answer 28

Endoscopic banding (bands stay on for 4 days, allow veins to scar up, reduces vascularity of the oesophagus)
Initiate B-blocker
Treat underlying cause
Continue course of banding every ~3/12 until varices healed