Gastroenterology: Upper GI & variceal bleeds

Question 1

What are the symptoms of an upper GI bleed?

Answer 1

1) Haematemesis - coffee-ground vomit or blood
2) ± malaena - black, tarry stools

Question 2

How can the observations in a patient determine the extent of blood loss in an upper GI bleed?

Answer 2

1) Resting tachycardia = mild-moderate hypovolaemia (<15% of blood volume lost)
2) Orthostatic hypotension = at least 15% blood volume loss
3) Supine hypotension = > 40% blood volume loss

Question 3

What are the causes of upper GI bleeds?

Answer 3

1) Oesophageal/gastric varices
2) Peptic ulcer disease (H. pylori, NSAID use, smoking)
3) Malignancy
4) Mallory-Weiss tear
5) Aorto-enteric fistula (previous AAA or an aortic graft)
6) Angiodysplasia

Question 4

What are the three extra things you need to consider in upper GI bleeds?

Answer 4

1) If the patient is more susceptible to the effects of anaemia e.g. in CAD
2) If the patient is at risk of fluid overload with aggressive resuscitation e.g. renal disease, heart failure
3) If bleeding will be harder to control e.g. anticoagulation, liver disease or thrombocytopenia

Question 5

Which patient are more susceptible to the effects of anaemia in an upper GI bleed?

Answer 5

Coronary artery disease

Question 6

Which patients are at risk of fluid overload with aggressive resuscitation in an upper GI bleed?

Answer 6

Heart failure, renal disease

Question 7

In which patients will bleeding be harder to control in an upper GI bleed?

Answer 7

Anticoagulation, liver disease or thrombocytopenia

Question 8

How do you fluid resuscitate a patient with an upper GI bleed?

Answer 8

1) IV fluid resuscitation
2) ± blood transfusion - if Hb < 7
3) ± platelets/vitamin K - if clotting abnormalities
4) ± fresh frozen plasma (every 4th unit of blood)

Question 9

How do you acutely manage a patient with an upper GI bleed?

Answer 9

ABCDE assessment
1) IV fluid resuscitation ± transfusion
2) NBM
3) Oxygen
4) ± IV PPI
5) ± IV terlipressin + abx - in variceal bleeding

Question 10

How do you manage a patient with an upper GI bleed once they are stable?

Answer 10

Urgent upper GI endoscopy

Question 11

What is the role of upper GI endoscopy in an upper GI bleed?

Answer 11

1) Locate the source of the bleeding
2) Attempt to stop further bleeding through various mechanisms e.g. adrenaline injection and ulcer clipping

Question 12

What two scores are used to decide whether a patient with an upper GI bleed should have an inpatient or outpatient endoscopy?

Answer 12

1) Rockall score
2) Glasgow-Blatchford score (preferred by NICE)
If score 0 = outpatient OGD

Question 13

What else does the Rockall score calculate?

Answer 13

Risk assessment tool that predicts mortality in upper GI bleed patients (pre-endoscopy max score = 7, post-endoscopy max score = 11)

Question 14

What scores you 0 points on the Rockall score?

Answer 14

1) Age < 60
2) SBP > 100
3) HR < 100
4) No comorbidities
5) Mallory Weiss tear (post endoscopy diagnosis)
6) No blood or dark red spot (at endoscopy)

Question 15

What are the components of the Glasgow-Blatchford score?

Answer 15

1) Urea
2) Hb
3) Systolic BP
4) Tachycardia
5) Clinically observed malaena
6) Syncope
7) Liver disease
8) Heart failure

Question 16

What causes oesophageal varices?

Answer 16

1) Portal hypertension - secondary to cirrhosis
2) These dilated veins tend to be fragile and more likely to bleed bc of high portal pressures

Question 17

What is a major cause of mortality in patients with cirrhosis?

Answer 17

Variceal bleeding

Question 18

What should patients be screened for when they are diagnosed with cirrhosis?

Answer 18

The presence of oesophageal varices by upper GI endoscopy

Question 19

After screening, how are oesophageal varices managed in patients with cirrhosis?

Answer 19

1) If no varices found - undergo repeat endoscopy after 2-3 years
2) Grade 1 varices with red signs or grade 2/3 varices = primary prophylaxis

Question 20

How are varices graded?

Answer 20

Grade 1 (small) to 3 (large)

Question 21

What additional treatments are given to manage upper GI bleeds that are a result of oesophageal varices?

Answer 21

1) IV terlipressin
2) Broad spectrum antibiotics

Question 22

What is terlipressin and why is it used to manage bleeding from oesophageal varices?

Answer 22

1) Vasopressin analogue
2) Causes splanchnic vasoconstriction, reducing portal pressure and bleeding from varices
3) Reduces mortality in patients with variceal haemorrhage

Question 23

Why are broad spectrum antibiotics given in variceal bleeding?

Answer 23

Reduce mortality by reducing the risk of bacteraemia and spontaneous bacterial peritonitis

Question 24

How do you manage variceal bleeding once the patient has been haemodynamically resuscitated?

Answer 24

1) Urgent endoscopy - ideally within 24h
2) At endoscopy - variceal band ligation = treatment of choice
3) If bleeding is uncontrollable, a Sengstaken-Blakemore tube may be inserted as a temporary measure to tamponade the bleeding varices
4) For patients with a history of alcoholism, thiamine may be required to correct any deficiency

Question 25

What is the first line treatment for variceal bleeding (once the patient is stable)?

Answer 25

Urgent endoscopy + variceal band ligation

Question 26

How can you manage a variceal bleed if bleeding is uncontrollable?

Answer 26

Insert a Sengstaken-Blakemore tube = temporary measure to tamponade the bleeding varices

Question 27

What additional treatment would you give in variceal bleeding for patients with a history of alcoholism?

Answer 27

Thiamine (Pabrinex)

Question 28

What are the two methods used as prevention of variceal bleeding?

Answer 28

1) Non-selective beta blockers e.g. propanolol
2) Endoscopic - variceal band ligation

Question 29

What is an option for variceal bleed prevention in patients where pharmacological + endoscopic prevention fails?

Answer 29

Transjugular intrahepatic portosystemic shunt (TIPSS)

Question 30

What is a pre-hepatic cause of portal hypertension?

Answer 30

1) Thrombosis (portal or splenic vein) Risk factors for variceal bleeds: Portal pressure, variceal size, endoscopic features of the variceal wall (eg haematocystic spots) and Child–Pugh score ≥8 (p261).95

Question 31

What are intrahepatic causes of portal hypertension?

Answer 31

1) Cirrhosis (80% in UK)
2) Schistosomiasis (commonest worldwide)
3) Sarcoid
4) Myeloproliferative diseases
5) Congenital hepatic fibrosis

Question 32

What are post-hepatic causes of portal hypertension?

Answer 32

1) Budd–Chiari syndrome
2) Right heart failure
3) Constrictive pericarditis
4) Veno-occlusive disease

Question 33

What are risk factors for variceal bleeding?

Answer 33

1) Portal pressure
2) Variceal size
3) Endoscopic features of the variceal wall e.g. haematocystic spots
4) Child–Pugh score ≥ 8

Question 34

What is a transjugular intrahepatic portosystemic shunt (TIPS or TIPSS)?

Answer 34

An artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein

Question 35

What does TIPS do?

Answer 35

1) Achieves portal decompression
2) Manages some of the major complications of portal hypertension

Question 36

What is TIPS used to manage?

Answer 36

Portal hypertension

Question 37

What are indications for TIPS?

Answer 37

1) Secondary prophylaxis for oesophageal variceal bleeding
2) Treatment of refractory ascites
3) Treating portal hypertension in Budd-Chiari syndrome

Question 38

What is the key side effect of TIPSS?

Answer 38

Hepatic encephalopathy - the procedure can worsen or cause HE

Question 39

What is peritonitis?

Answer 39

Inflammation of the peritoneum

Question 40

What are signs of peritonitis on examiantion?

Answer 40

1) Abdominal rigidity/involuntary abdominal guarding - involuntary tensing of the abdominal wall muscles in response to pressure on the abdomen (to protect inflamed abdominal organs)
2) Rebound tenderness i.e. pressing on the abdomen elicits less pain than releasing the hand (because the peritoneum bounces back into place)

Question 41

What are the other features of peritonitis?

Answer 41

1) Fever
2) Vomiting
3) Tachycardia
4) Hypotension

Question 42

What are the two types of causes of peritonitis?

Answer 42

1) Perforation of a hollow viscus
2) Infection

Question 43

What are causes of peritonitis that can perforation of a hollow viscus?

Answer 43

1) Perforated oesophagus (Boerhaave syndrome)
2) Perforated duodenal/gastric ulcer
3) Perforated intestine - secondary to e.g. appendicitis, diverticulitis, intestinal infarction, colorectal cancer, or IBD
4) Trauma e.g. ingestion of a foreign body

Question 44

What are infectious causes of peritonitis?

Answer 44

1) Spontaneous bacterial peritonitis
2) Peritoneal infection secondary to peritoneal dialysis
3) Sterile fluids can leak into and irritate the peritoneum e.g. leakage of blood (e.g. in blunt abdominal trauma), bile (e.g. in liver biopsy), and pancreatic fluids (e.g. in acute pancreatitis)

Question 45

What is Boerhaave’s syndrome?

Answer 45

Spontaneous rupture of the oesophagus that occurs during intense straining (forceful/repeated vomiting) - can cause peritonitis