Upper GI Bleed

Question 1

What is upper GI Bleed

Answer 1

Bleeding from the GI tract where the source of bleeding is proximal to the duodenal-jejunal flexure/ligament of treitz

Question 2

Non-variceal bleed causes (4)

Answer 2

• Peptic ulcer
• Acute abdominal lesions: gastritis and stress ulcers
• Mallory Weis tears
• Tumors : gastrointestinal stromal tumor

Question 3

Obscure causes of Upper GI bleed (4) and Miscellaneous causes

Answer 3

Cameron ulcers
Haemobilia
Aorto enteric fistulas
Clotting abnormalities

Miscellaneous:
Pharynx : nose bleeds , hemoptysis and naso/oropharyngeal lesions

Question 4

RUQ pain, jaundice and upper GI bleed

Answer 4

Haemobilia

Question 5

What are the 3 specific features of upper GI bleed

Answer 5

1. Haematemesis
2. Coffee ground vomiting
3. Melaena

Question 6

Mention 5 specific measures taken in patients with suspected variceal hemorrhage

Answer 6

1. Antibiotic prophylaxis for spontaneous bacterial peritonitis
2. Recombinant factor Vll
3. Lactulose
4. Monitor blood glucose
5. Give Thiamine in alcoholics

Question 7

What’s the indication for emergency surgery without further diagnostic evaluation and where is it contraindicated

Answer 7

1. Massive upper GI bleed unless the oesophageal varices are suspected as the probable cause of bleeding

Question 8

What are 6 points that are important on history and examination

Answer 8

1. Evaluate for symptoms of PUD ,as well as it’s risk factors
2. Examine the pt for stigmata of chronic liver disease
3. Examine the pt for signs of portal HPT
4. Evaluate the pt for signs of metastatic stomach cancers
5. Perform a rectal exam to evaluate the appearance of blood
6. Ask specifically about clotting abnormalities and warfarin therapy

Question 9

Which subgroup of patients is more prone to dying from bleeding

Answer 9

1. Older than 60 yrs
2. Cardiac,pulmonary, liver or renal disease
3. Severity of bleeding episodes : haematemesis, Hb less than 8 and shock with BP less than 100

Question 10

When can an upper GI endoscopy be done as an emergency

Answer 10

1. If oesophageal varices are suspected

2. Signs of ongoing bleeding

Question 11

What are the four endoscopic treatment modalities:

Answer 11

1. Injection : adrenaline with saline, sclerosant
2. Mechanical : rubber band ligation
3. Thermal: laser
4. Topical : collagen

Question 12

How should patients with stigmata for rebleeding be treated?

Answer 12

-Ideally with two endoscopic modalities followed by high dose of proton pump inhibitors

Question 13

Who benefits from Endoscopic treatment? And who does not

Answer 13

• patients with active bleeding or if there is a visible vessel will benefit And
• patients with minor stigmata for rebleeding or clean ulcer base do not benefit

Question 14

What are the indications for surgery

Answer 14

1. Massive bleeding
2. Continuous bleeding
3. Rebleeding to shock
4. Older patients with higher risk of mortality and strong stigmata for rebleeding on endoscopy

Question 15

What sclerosants do we give for oesophageal varices? And what do we use for varices in the stomach

Answer 15

1. Ethanolamine olate
2. STD : sodium tetradecyl sulphate

And we use cyano achrominate glue because rubber band cannot work since the mucosa of the stomach is not pliable

Question 16

What do we use it the patient continues to bleed after endoscopic therapy ?

Answer 16

Balloon compression or pharmacotherapy

Question 17

What will be the next step to control bleeding oif the pt is a very poor general risk or if she qualifies for a liver transplant

What are the two selective shunts?

Answer 17

Transjugular intrahepatic portosystemic shunt (TIPS)

Two selective shunts:

1. Splenorenal shunt
2. Inocushi shunt

Question 18

What is the long term control of recurrent varices

Answer 18

Propanolol