Varices and upper GI bleed

Question 1

How can Upper GI bleeds present?

Answer 1

Haematemesis
Coffee ground emesis
return of bright red blood through NG
Melaena

Question 2

what are the causes of upper GI bleeds

Answer 2

PUD  
Gastritis/erosions 
Oesophagitis 
erosive duodenitis 
Varices
Mallory weiss tear 
Malignancy

Question 3

What are the scoring systems for Upper GI bleed?

Answer 3

Rockall score

• predicts mortality
• takes age, shock and comorbidity into account

Glasgow Blatchford scale

• predicts need for intervention
• takes urea, Hb, SBP and other features into account
• score of 1 or less = outpatient endoscopy

Question 4

what are some signs of shock?

Answer 4

Peripherally cool and clammy 
CRT >2secs 
Urine output <0.5ml/kg/hr
Tachycardic 
SBP <100mmHg

Question 5

What are the immediate management steps in an upper GI bleed?

Answer 5

IV access and send off bloods inc G&S
IV crystalloid fluids
Insert catheter and monitor UO
Transfuse if Hb <70
IV PPI, 80mg bolus then IVI at 8mg/hr for 3 days
Stop any aspirin, NSAIDS, anticoagulants and correct any clotting abnormalities
Urgent endoscopy within 24hrs

Question 6

what endoscopic interventions can be done for an upper GI bleed?

Answer 6

adrenaline injection
heater probe for thermal coagulation
clipping
haemostatic powders

Question 7

how is an acute variceal bleed managed?

Answer 7

Resusicate until haemodynamically stable - IV crystalloids and blood products

IVI of terlipressin 1-2mg/6 hrs for <3 days
- causes selective splanchnic and extrarenal vasoconstriction

IV Abx

• reduced bacteraemia and prevent SBP
• Co-amoxiclav or ciprofloxacin preferred

Endoscopy and band ligation

Tranjugular intrahepatic portosystemic shunt (TIPS)

if bleeding uncontrolled then sengstaken or minnesota tube inserted

Question 8

what is given prophylactically to prevent variceal bleeding?

Answer 8

B-blocker e.g propanolol

Question 9

where do oesophageal varices commonly arise?

Answer 9

anastomoses of left gastric and left azygous vein

Question 10

what causes oesophageal varices?

Answer 10

Portal hypertension

Question 11

What is the classification for portal HTN causes with examples?

Answer 11

prehepatic

• portal vein occlusion
• splenic vein occlusion
• portal vein stenosis or compression

Hepatic

• Cirrhosis
• Sarcoidosis
• alcoholic hepatitis

Post hepatic

• constrictive pericarditis
• restrictive cardiomyopathy

Question 12

what investigations can be done in portal HTN and varices?

Answer 12

Hepatic venous pressure gradient

• HVPG 5-10mmHg = compensated cirrhosis and mild portal HTN
• > 10mmHg = compensation cirrhosis but significant portal HTN
• > 12mmHg = bleeding risk

OGD

• Dilated veins in lower oesophagus
• red wale marks

FBC
- microcytic anaemia and thrombocytopenia

LFTs

• Transaminits and increased alk phos and bilirubin
• prolonged coag also

Question 13

what are red wale marks and why are they important?

Answer 13

they are longtitudinal dilated venules resembling whip marks on the surfaces of varices and they are an important indicator of bleeding risk