GI - Upper gastro bleeding

Question 1

What does melaena imply in terms of the origin of bleeding?

Answer 1

melaena implies the blood has undergone some digestive action and that the source is proximal to the ileocaecal valve

But torrential loss from an Upper-GI source may result in passage of bright-red blood per rectum

Question 2

When Is the bleeding haemodynamically significant?

Answer 2

1) external evidence of blood loss, greater than 500ml
2) resting tachycardia: pulse ≥ 100 beats/min (patients on beta-blockers may not exhibit a tachycardia)
3) systolic blood pressure : ≤ 100 mmHg (BP of 110 may not be “normal” for elderly patients)
4) orthostatic hypotension : pulse increase of ≥ 20 beats/min or decrease in systolic pressure of ≥ 20 mmHg

Question 3

Rx of Upper GI significant bleeding

Answer 3

1) A portal for transfusion must be established – two large-bore 16 to 18 gauge IV-cannula
2) A supply of blood must be obtained
3) An early, indeed urgent effort must be made to arrive at an anatomical diagnosis

Restoration of normovolaemia:

1) Rapid infusion of crystalloids
2) Transfusion of colloids - plasma substitutes
3) Packed cells and/or whole blood
4) Consider CVP monitoring
5) Urinary output monitoring with cathether

Question 4

Common causes of upper GI bleeding

Answer 4

Peptic ulcer disease 45% 
Oesophageal varices 15% 
Gastro-duodenal erosions 10%
 Mallory-Weiss tear 7% 
Angioectasias 7% 
Oesophagitis 5% 
Upper GI-Tumour 5% 
Gastropathy 2% 
Large Hiatus Hernia 2% 
Dieulafoy lesion 2% 
Aorto-enteric fistula

Ask about: history of heavy drinking, known peptic ulcer with or without surgery; NSAID ingestion; chronic liver disease; abdominal aortic aneurysm; anti-coagulant medications