GI Haemorrhage

Question 1

define upper GI bleed

Answer 1

bleeding form the oesophagus, stomach and duodenum

Question 2

define lower GI bleed

Answer 2

bleeding from the small bowel ad colon

Question 3

define haematemesis

Answer 3

vomiting of fresh blood from the upper GI tract

Question 4

what is coffee-ground vomitus?

Answer 4

vomiting of black material which is assumed to be partly digested blood
its presence implies that bleeding has ceased or has been relatively modest

Question 5

define melaena

Answer 5

passage of dark tarry black stool usually due to an acute upper GI bleed

Question 6

define haematochezia. what can cause it?

Answer 6

passage of fresh or altered blood per rectum usually due to colonic bleeding
can sometimes be due to profuse upper GI or small bowel bleeding

Question 7

list the possible causes of haematemesis and melaena

Answer 7

• Peptic ulcer disease
• Erosive gastritis
• Mallory-weiss tear (laceration in mucosa at the junction of the stomach and oesophagus)
• Oesophagitis due to GORD
• Ruptured oesophageal varices
• Vascular abnormalities, such as angiodysplasias
• Gastric neoplasm

Question 8

what additional questions would you ask a patient presenting with haematemesis and melaena?

Answer 8

• non-specific symptoms of hypovolaemia
• symptoms of chronic blood loss - anaemia symptoms
• heartburn (oesophagitis)
• weight loss - carcinoma
• dysphagia (difficulty swallowing), odynophagia (painful swallowing) - oesophagitis or oesophageal carcinoma
• retching (especially after alcohol binge) - mallory -weiss tear
• abdominal pain
• known liver disease/oesophageal varices
• check drugs - NSAIDs, aspirin, steroids, thrombolytics

Question 9

which non-specific symptoms of hypovolaemia must you ask about in a patient presenting with haematemesis and melaena?

Answer 9

• faintness
• weakness
• dizziness
• sweating
• palpitations
• dyspnoea
• pallor
• collapse

Question 10

what would sudden severe abdominal pain in a patient with haematemesis and melaena suggest?

Answer 10

possible bowel perforation

Question 11

what would intermittent epigastric pain in a patient with haematemesis and melaena suggest?

Answer 11

peptic ulceration

Question 12

what are the scoring systems used in upper GI bleeds?

Answer 12

Rockall score and Blatchford score

Question 13

which parameters are measured when calculating a Rockall risk score?

Answer 13

pre-endoscopy: age, systolic BP and pulse rate, comorbidity

post-endoscopy: diagnosis and signs of recent haemorrhage on endoscopy

Question 14

what does the rockall score indicate?

Answer 14

GI bleed mortality initially

the pre-endoscopy criteria is added to post-endoscopy criteria to calculate the risk of mortality after endoscopy

Question 15

what is the NICE guidance regarding using scoring systems in acute upper GI bleeds?

Answer 15

calculate Blatchford score first - if score of 0 then consider early discharge
calculate Rockall score post-endoscopy (each centre has their own cut-offs for admission)

Question 16

what parameters are measured to calculate a Blatchford score in patients with acute upper GI bleeding?

Answer 16

• laboratory results such as haemoglobin and BUN
• history of melaena
• history of cardiac failure
• history of hepatic disease
• recent syncope
• sex
• heart rate
• BP

Question 17

what are the signs of shock?

Answer 17

• Peripherally cool/clammy
• Cap refill time >2s
• Urine output <0.5 mL/kg/h
• Decreased GCS or encephalopathy
• Tachycardia
• Systolic BP <100mmHg; postural drop >20mmHg

Question 18

describe the immediate management, step by step, for a patient with a suspected GI bleed with shock

Answer 18

1. protect airway and keep NBM. insert 2 large-bore cannulae
2. urgent bloods - FBC, U&E, LFT, Glucose, clotting screen, cross-match 4-6 units
3. Rapid IV crystalloid infusion up to 1L to maintain BP
4. if grade III or IV shock, give blood group specific or O- blood
5. correct clotting abnormalities - vitamin K, fresh frozen plasma, platelet concentrate
6. if risk of varices, give terlipressin IV 1-2mh/6h and broad-spectrum IV antibiotics
7. consider referral to IVU or HDU
8. catheterise and monitor urine output (aim for >30 mL/h)
9. monitor vital signs every 15 mins until stable, then every hour
10. notify surgeons
11. urgent endoscopy after adequate resuscitation

Question 19

what makes a bleed seen on endoscopy ‘high risk’?

Answer 19

active bleeding
adherent clot
non-bleeding visible vessel

Question 20

what makes a bleed seen on endoscopy ‘low risk’?

Answer 20

flat, pigmented spot or clean base

Question 21

how are high-risk bleeds due to peptic ulceration treated?

Answer 21

◦ 2 of: clips, cautery, adrenaline
◦ Start PPI
◦ If haemodynamically stable, start oral intake of clear fluids 6h after endoscopy
◦ Treat if positive for H.pylori

Question 22

how are low-risk bleeds due to peptic ulceration treated?

Answer 22

◦ No need for endoscopic haemostasis
◦ Consider early discharge if patient otherwise low risk
◦ Give oral PPI
◦ Regular diet 6h after endoscopy if stable
◦ Treat if positive for H.pylori

Question 23

how are gastro-oesophageal variceal bleeds managed acutely?

Answer 23

• endoscopic banding (oesophageal)

- sclerotherapy - causes blood clotting in veins (gastric)

Question 24

what is the prophylaxis of variceal bleeding in someone with known gastro-oesophageal varices?

Answer 24

• beta blockade (propranolol)

- repeat endoscopic banding