Causes of Upper GI Bleeding

Question 1

Causes of upper GI bleeding

Answer 1

Mallory-weiss tear
Oesophago-gastric varices
Peptic ulcer

Question 2

What is a Mallory-Weiss tear

Answer 2

This is a linear mucosal tear occurring at the oesophagogastric junction and
produced by a sudden increase in intra-abdominal pressure
Lead to bleeding

Question 3

Clinical presentation of Mallory-Weiss tear

Answer 3

Bout of retching or vomiting -> Haemetesis

Others: Syncope, light headedness, dizziness

Question 4

Pathophysiology of Mallory-Weiss tear

Answer 4

Sudden increased intragastric pressure within the non-distensible lower oesophagus can cause tearing of the mucosa.
Blood then enters the oesophagus and is vomited out

Question 5

Aetiology of Mallory-Weiss tear

Answer 5

Trauma from frequent cough, vomit, retching or even hiccuping
RF: Excessive alcohol consumption; NSAIDs

Question 6

Epidemiology of Mallory-Weiss tear

Answer 6

2-8% all Upper GI bleeding
Bulimics and alcoholics
Males aged 20-50

Question 7

Diagnosis of Mallory-Weiss tear

Differentials

Answer 7

*Endoscopy (confirms)
Differential diagnosis:
Gastroenteritis; peptic ulcer; oesophageal varices

Question 8

Treatment of Mallory-Weiss tear

Answer 8

Resuscitation
Maintain airway, high flow oxygen, correct fluid losses
Identify co-morbidities
Tear tends to heal rapidly

Question 9

Complications of Mallory-Weiss tear

Answer 9

Hypovolaemic shock (and death)
Rebleeding
MI
Such bleeding rare

Question 10

What are Oesophago-Gastric varices

Answer 10

Dilated veins at the junction between the portal and systemic venous systems leading to variceal haemorrhage

Question 11

Clinical presentation of Oesophago-Gastric varices

Answer 11

Haematemesis
Liver disease
Pallor
Shock (low BP/ high HR)

Question 12

Pathophysiology of Oesophago-Gastric varices

Answer 12

Liver disease leads to high pressure in the portal veins -> veins at the junction with systemic venous system distend (varices).
This causes damage and can lead to bleeding from the varices into the oesophagus -> Haematemesis

Question 13

Aetiology of Oesophago-Gastric varices

Answer 13

Portal hypertension

Majority of patients with oesophageal varices have chronic liver disease

Question 14

Epidemiology of Oesophago-Gastric varices

Answer 14

10-20% of all Upper GI bleeding

Question 15

Diagnosis of Oesophago-Gastric varices

Answer 15

Endoscopy

Question 16

Treatment of Oesophago-Gastric varices

Answer 16

Resuscitation
Maintain airway
Treat shock
other:
Vasoactive drugs
Endoscopic band ligation
Antibiotics as prophylaxis
Can obturate with glue like substance

Question 17

Complications of Oesophago-Gastric varices

Answer 17

70% chance of rebleeding

Significant risk of death

Question 18

What is a peptic ulcer

Answer 18

Break in the GI mucosa in or adjacent to acid bearing area

Question 19

Types of peptic ulcer

Answer 19

Gastric

Duodenal

Question 20

What % of Gastric peptic ulcer is H.pylori associated with?

Answer 20

80%

Question 21

What % of Duodenal peptic ulcer cases is H.pylori associated with?

Answer 21

95%

Question 22

Where in stomach can H.pylori be found

Answer 22

Mucus layer

Question 23

Clinical presentation of peptic ulcer

Answer 23

Burning epigastric pain. Nausea, heartburn, and flatulence. Occasionally painless haemorrhage.
(Not vomiting)

Question 24

Difference in clinical presentation between duodenal and gastric peptic ulcer

Answer 24

Duodenalmore pain when the patient is hungry, and at night.

Question 25

Pathophysiology of peptic ulcer

Answer 25

Depending on the aetiology, a reduction in protective prostaglandins or an increase in gastric acid secretions causes the acidic contents of the stomach/duodenum to break down the mucosa. Pain varies with the acid level of the area affecting the ulcer. H. pylori can infect mucosa following this damage -> further damage through inflammation and proteases.

Question 26

**Aetiology of peptic ulcer

Answer 26

H. pylori, Bile Regurgitation, Ischaemia of mucus producing cells and NSAIDs. H. pylori: Increased gastric acid secretions. Disruption of mucous protective layer. Reduced duodenal bicarbonate production NSAIDs (Ibuprofen): Inhibit cycloxygenase-1 which inhibits production of prostaglandins needed for mucous production and provide mucosal protection in the upper GI - thus mucousal damage. Ischaemia, reducing blood flow to mucus secreting cells, therefore less mucus secreted and so acid of stomach destroys these cells and over time causes ulceration. Bile regurgitation

Question 27

Epidemiology of peptic ulcers

Answer 27

50% of all Upper GI bleeding | Duodenal 2-3x more common than gastric

Question 28

*Diagnosis of peptic ulcers

Answer 28

``` Testing for H.pylori: Urea breath test, serology or stool antigen test Alternatively endoscopy (but more invasive) ```

Question 29

Treatment of peptic ulcers

Answer 29

``` Avoid NSAIDs Cessation of smoking Eradication of H.pylori through 2 antibiotics and PPI ->Triple therapy: Lansoprazole (PPI) Clarithromycin Metronidazole or Amoxicillin Antacids also helpful ```

Question 30

Complications of peptic ulcers

Answer 30

Can cause upper GI bleed | Peritonitis if continues to grow

Question 31

Prevention of bleeding from vatical haemorrhage

Answer 31

* Non-selective B-blockade e.g. PROPRANOLOL to reduce resting pulse rate to decrease portal pressure * Variceal banding repeatedly (to obliterate varices) * Liver transplant - best option when there is poor liver function

Question 32

Initial management of bleeding from variceal haemorrhage

Answer 32

- Resuscitate until haemodynamically stable - If anaemic then BLOOD TRANSFUSION aiming to get Hb to 80g/L - Correct clotting abnormalities -> administer VITAMIN K and PLATELET TRANSFUSION - Vasopressin -> IV TERLIPRESSIN -> to cause vasoconstriction, (use IV SOMATOSTATIN if terlipressin is contraindicated e.g. in ischaemic heart disease) - Prophylactic antibiotics to treat and prevent infection as well as reduce early rebleeding and mortality e.g. CEPHALOSPORIN - Variceal banding - Ballon tamponade to reduce bleeding by placing pressure on varice if banding fails

Question 33

What is variceal banding

Answer 33

where a band is put around varice using an endoscope, after a few days the banded varix degenerates and falls off leaving a scar

Question 34

How do NSAIDs cause mucosal damage

Answer 34

NSAIDs inhibit cyclooxygenase-1 which inhibits the production of prostaglandins needed for mucous production, leading to mucosal damage

Question 35

Medical treatment of oesophageal varices

Answer 35

Beta blocker to reduce CO -> reduce portal pressure Nitrate to reduce portal pressure Terlipressin – analogue of ADH -> reduce portal pressure

Question 36

Surgical treatment of oesophageal varices

Answer 36

Band ligation | Transjugular intrahepatic portosystemic shunt (TIPSS)