Management of Acute Upper GI Haemorrhage

Question 1

how might GI bleeding present?

Answer 1

haematemesis (thick, black, blood clotted vomit)

Melaena (thick, black, sticky, blood clotted stool)

Question 2

How serious is GI bleeding?

Answer 2

can be major life threatening medical emergency
Must be considered severe until proven otherwise
Most are self limiting with no in-hospital re-bleeding
Continued/recurrent bleeding = 30-40% mortality
Death due to complications

Question 3

what are the most common causes of GI bleeding?

Answer 3

1) duodenal ulcer
2) gastric erosions
3) gastric ulcer
4) varices
5)Mallory-Weiss tear
others = oesophagitis, duodenitis, ulcers, neoplasm etc

Question 4

what has contributed to the slight decrease in mortality from GI bleeding?

Answer 4

development of endoscopy
discovery of H.pylori
development of omeprazole etc

Question 5

what is the most important management of GI bleeding?

Answer 5

recuscitation:
A.irway
B.reathing
C.irculation

first thing = Airway protection:

• oxygen
• IV access (largest bore cannula - grey one)
• fluids

Question 6

what is the 100 rule?

Answer 6

assesses severity of the haemorrhage
considered severe if:
- systolic BP <100
- pulse >100
- Hb <100
- age >60
- comorbid disease
- postural drop in BP

Question 7

who have good and bad compensation for bleeding?

Answer 7

diabetics = bad
young people = compensate then crash hard
Older = bad
People taking beta-blockers = bad

Question 8

what are the 3 functions of endoscopy in GI bleeding?

Answer 8

identify cause
therapeutic manoeuvres
Assess risk of rebleeding

Question 9

what is the Rockall scoring system?

Answer 9

point scoring system for assessing risk of rebleeding in GI haemorrhage patients

Question 10

what is the Blatchford score?

Answer 10

point scoring system for assessing risk of rebleeding in GI haemorrhage patients
Uses different criteria than Rockall system

Question 11

what are the benefits of the Blatchford score over the Rockall score?

Answer 11

it doesn’t require endoscopy

Question 12

what are the ranges of Blatchford score and what do they mean?

Answer 12

0-1 = low risk bleed
2-5 = intermediate risk bleed
6+ = high risk bleed

Question 13

what does bleeding from a peptic ulcer look like?

Answer 13

blood spurting into the lumen

Question 14

what are the 3 criteria used to diagnose recent haemorrhage?

Answer 14

active bleeding
overlying clot
visible vessel

Question 15

what treatments are available for peptic ulcer bleeding?

Answer 15

endoscopic treatment (high risk ulcers)
Acid suppression
Surgery
H.pylori eradication (secondary prevention)

Question 16

what possible treatments can be delivered via endoscopy?

Answer 16

injection (adrenaline - causes balance to favour thrombotic over thrombolysis so pepsin and acid don’t dissolve clot)
heater probe coagulation
Combinations (injection + heater probe/clip = best)
Clips
Haemospray

Question 17

what is haemospray?

Answer 17

powder spray which is applied to the area of the ulcer to stop the bleeding by absorbing all the water from the area causing a clot to form
Used if clips etc don’t work

Question 18

what is acid suppression?

Answer 18

PPI
eg. omeprazole
Used after bleeding has stopped
Prevents rebleeding
Reduces need for surgery
Everyone gets it

Question 19

when is surgery performed in peptic ulcer bleeding?

Answer 19

if adrenaline injection/heater probe/clips don’t control the bleed
OR
rebleed which is not controlled by endoscopic therapy (injection, clips etc)

Question 20

who is likely to get varices?

Answer 20

people with liver disease (chirrosis)

Question 21

what are the risk factors for varices bleeding?

Answer 21

portal pressure >12mmHg
varices >25% of oesophageal lumen
presence of red signs
degree of liver failure (childs A<b></b>

Question 22

what is mortality like from varices bleeding?

Answer 22

25-50%

due to complications (sepsis, liver failure)

Question 23

how do varices arise in cirrhosis?

Answer 23

as cirrhosis progresses, the resistance of the liver to flow from the portal vein increases increasing portal vein pressure, causing back pressure in all surrounding vessels and at the G.O junction, drainage above this is usually through azygous vein and portal vein (posteriorly), when pressure rises the blood tries to find another way back to systemic circulation, so goes upwards into the azygous causing distension of oesophageal veins

Question 24

when would you expect varices in a bleeder?

Answer 24

known history of cirrhosis with varices, alcohol excess, viral hepatitis, metabolic/autoimmune liver disease, abdominal sepsis/surgery

Question 25

what would be seen on examination in varices?

Answer 25

stigmata of chronic liver disease

Question 26

what does an oesophageal varice look like?

Answer 26

big, distended, spongey vein inside the oesophagus

Question 27

what are the aims of management in varices bleeding?

Answer 27

resuscitation
haemostasis
prevent complications
prevent deterioration of liver

Question 28

what should be considered in varices treatment?

Answer 28

coagulopathy (low platelets in cirrhosis/alcoholics)
CVP monitoring
parenteral vitamins
antibiotics (sepsis risk)
unexpected pathology (eg. perforated D.U)
hypoglycaemia (liver dysfunction)
replace K, Mg and PO4
delirium treatments

Question 29

how can haemostasis be achieved?

Answer 29

terlipressin (vasopressin analogue)
endoscopic variceal ligation (banding)
sclerotherapy
sengstaken-blakemore balloon
TIPS

Question 30

what is teripressin?

Answer 30

vasopressin prodrug
splanchic vasoconstrictor
beneficial in renal perfusion
better than vasopressin, statins, octreotide

Question 31

what is sclerotherapy?

Answer 31

injection of chemical into a vessel to obliterate it

Question 32

what is sengstaken-blakemore balloon?

Answer 32

tube inserted via nose/mouth, balloon inflates inside stomach to restrict flow to varices

Question 33

what is TIPS?

Answer 33

Transjugular intrahepatic portosystemic shunt
treats gastric bleeding
creates communication beween inflow and outflow veins in liver