Case 1 - Upper GI bleeding

Question 1

Common risk factors for GI bleeding

Answer 1

• Anticoagulants
• NSAID use
• Varicies/chronic liver disease

Question 2

Important clinical examination findings to document for upper GI bleed

Answer 2

• BP
• HR
• Malaena?
• Haematemesis/coffee ground vomit?
• Signs of chronic liver disease - spider naevi, clubbing, gynaecomastia, palmar erythema
• Renal failure signs
• Heart failure signs

Question 3

Investigations for upper GI bleed

Answer 3

• FBC - Hb, platelets
• U&Es - increased urea can be a sign for upper GI bleed
• Clotting
• Group and Save
• Crossmatch
• LFTs - CLD
• VBG - get Hb fast
• Endoscopy maybe?

Question 4

Why do you get high urea in upper GI bleed?

Answer 4

• Blood is digested to protein
• PRotein transported to the liver
• Broken down into BUN in urea cycle (blood urea nitrogen)

Question 5

What scoring system is used for upper GI bleeding?

Answer 5

• Glasgow Blatchford score - first assessment, assess if can be managed as outpatient or inpatient
• Rockall score after endoscopy - perecentage risk of re-bleeding and mortality (split into pre and post endoscopy)

Question 6

What does ROCKALL score take into account?

Answer 6

• Age
• Features of shock
• Co-morbidities
• Aetiology of bleeding (cause)
• Stigmata of recent haemorrhge - blood in upper GI tract, spurting vessel, adherant clot

Question 7

What does Glasgow Blatchford score take into account?

Answer 7

• Urea
• Hb
• Systolic BP
• Other - pulse, malaena, syncope, hepatic disease, cardiac failure

Question 8

Immediate management for upper GI bleed patient - emergency

Answer 8

• A-E assessment
• Platelet transfusion if actively bleeding platelet count less than 50 x10^9
• FFP is fibrinogen less than 1g/litre or PT/aPTP more than 1.5x normal
• Prothrombin complex if on warfarin and actively bleeding
• Endoscopy after resucitation - must be within 24hrs

Question 9

Management of non-varcieal bleeding

Answer 9

• PPI if non-variceal and stigmata of recent bleeding shown on endoscopy
• No PPI if just non-variceal bleeding
• If further bleeding - repeat endoscopy, interventional radiology or surgery

Question 10

Management of variceal bleeding

Answer 10

Before endoscopy:
* Terlipressin
* Prophylactic abx

Then:
* Band ligation + injection of N-butyl-2-cyanoacrylate for patients with gastric varicies
* Sengstaken-Blakemore tube
* TIPs offered if bleeding not control via these measures (transjugular intrahepatic portosystemic shunt) (hepatic vein to portal vein connedction)

Question 11

When can we not give Terlipressin?

Answer 11

If history of ischaemic heart disease

Question 12

Monitoring for pt with upper GI bleed needed

Answer 12

• BP
• Monitor any vomit and stools passed

Question 13

Long term management of oesophageal varices - prevent bleeding

Answer 13

• Propanolol
• Endoscopic variceal band ligation (2 weekly intervals until eradiacted)
• TIPs

Question 14

Pathophysiology of oesophageal varices

Answer 14

• Cirrhosis = stiff, inexpansible liver
• Increased pressure in portal veins
• Increased pressure in portal venous sytem
• = portal venous system to systemic venous sytem shunt via anastomoses that are already present
• Dilated veins

Question 15

Pathophysiology of peptic ulcer disease

Answer 15

• Defect in gastric/duodenal mucosa that extends to muscularis mucosae
• RF inc NSAIDs, H-pylori, physiological stress

Question 16

Clinical features of upper GI bleeding

Answer 16

• Haematemesis
• Malena
• Raised urea - protein meal of blood
• Abdo pain if peptic ulcer
• CLD signs if oesophageal varices

Question 17

Differentials for upper GI bleed cause

Answer 17

• Oesophageal varices
• Oesophagitis
• Oesophageal ancer
• Mallory Weiss tear
• Gastric ulcer
• Gastric cancer