Upper Gastrointestinal Bleeding

Question 1

How is orthostatic hypertension defined?

Answer 1

Drop of 20 mmHg systolic BP from sitting > standing
AND/OR
Drop of 10 mmHg diastolic BP from sitting > standing
AND/OR
Increase in pulse of >20 bpm from sitting > standing

Question 2

What is haemetemesis?

Answer 2

Vomiting blood

Fresh/altered, source proximal to ligament of Treitz

Question 3

Where is the source of blood in melaena?

Answer 3

Proximal to ileocaecal valve

Question 4

When can an upper gastrointestinal source of blood result in passage of bright red blood per rectum?

Answer 4

Torrential loss

Question 5

What are many deaths associated with in upper gastrointestinal bleeding?

Answer 5

Decompensation of co-existing medical condition precipitated by acute bleeding event

Question 6

How can the gastroduodenal artery bleed?

Answer 6

Erosion of stomach ulcer can infiltrate gastroduodenal artery

Question 7

What are the measures of haemodynamically significant bleeding?

Answer 7

External evidence of blood loss >500 mL
Resting tachycardia
- If on beta blockers, may not have this
Systolic BP <100 mmHg
Orthostatic hypotension

Question 8

Who are high-risk patients in the case of upper gastrointestinal bleeding?

Answer 8

Clinical evidence of recurrent/ongoing bleeding
Syncope
Coexisting illness, especially ischaemic heart disease

Question 9

What is the management of high-risk patients in the case of upper gastrointestinal bleeding?

Answer 9

Triage to monitored setting
Consider admission to ICU
Multidisciplinary approach
Timely involvement of gastroenterologist and/or upper GI surgeons

Question 10

What is the immediate management of significant upper gastrointestinal bleeding?

Answer 10

2 large bore IV cannulas, as close to central circulation as possible
Supply of blood must be obtained
- Group and hold
- Crossmatch
Urgent effort to arrive at anatomical diagnosis

Question 11

How is normovolaemia restored?

Answer 11

Rapid infusion of crystalloids
- Usually 2 L of saline
Transfusion of colloids - plasma substitutes
Packed cells and/or whole blood
Consider central venous pressure monitoring
- Consider doing in HDU, or if going into theatre
Urinary output monitoring with catheter

Question 12

What are the most common causes of upper gastro-intestinal bleeding?

Answer 12

Peptic ulcer disease
Oesophageal varices
Gastro-duodenal erosions
Mallory-Weiss tear
Oesophagitis
Upper GI tumour

Question 13

What questions on history would you ask for a heametemesis presentation?

Answer 13

Alcohol intake
Known peptic ulcer with/without surgery
NSAID use
Chronic liver disease
Abdominal aortic aneurysm
Anticoagulant medications

Question 14

What leads to non-operative management of haemetemesis?

Answer 14

Successful endoscopic haemostasis

• Heat coagulation
• Adrenaline injection
• Clips for bleeding peptic ulcer/erosive gastritis
• Variceal ligation
• PPI infusion
• Octreotide infusion for varices

Question 15

What leads to surgery for haemetemesis?

Answer 15

Failed endoscopic haemostasis and ongoing rebleeding for peptic ulcer

Question 16

What leads to a “wait and see” approach in management of haemetemesis?

Answer 16

Bleeding stopped on endoscopy but possibility of further bleeding

Question 17

What is the Blatchford score?

Answer 17

Risk stratification of patients with upper GI bleeding

Higher scores = higher risk

Question 18

What is the management of acute bleeding from a peptic ulcer, at presentation?

Answer 18

Assess haemodynamic status
- Pulse
- BP
Obtain
- FBE
- UEC
- INR
- Blood type
- Cross-match
Start resuscitation
- Crystalloids
- Blood products
Consider NGT tube placement and aspiration
Consider starting treatment with IV PPI while waiting for early endoscopy
Perform early endoscopy - within 24 hours
Consider giving single 250 mg IV dose of erythromycin 30-60 min before endoscopy
Perform risk stratification

Question 19

Why is IV erythromycin given before an emergency endoscopy?

Answer 19

Speeds up gastric emptying

Question 20

What is the management of acute bleeding from a peptic ulcer, at early endoscopy?

Answer 20

Perform risk stratification

Question 21

What is a transjugular intrahepatic portosystemic shunt (TIPS)?

Answer 21

Connect portal vein with hepatic vein with shunt to reduce portal hypertension and its complications, especially variceal bleeding