Upper GI Bleed

Question 1

What is used to differentiate upper GI from lower GI bleed?

Answer 1

Raised urea

Question 2

What are the clinical features of upper GI bleed?

Answer 2

haematemesis
the most common presenting feature
often bright red but may sometimes be described as ‘coffee ground’
melena
the passage of altered blood per rectum
typically black and ‘tarry’
a raised urea may be seen due to the ‘protein meal’ of the blood
features associated with a particular diagnosis e,g,
oesophageal varices: stigmata of chronic liver disease
peptic ulcer disease: abdominal pain

Question 3

How does oesophagitis present?

Answer 3

Small volume of fresh blood, often streaking vomit. Melena rare. Often ceases spontaneously

Question 4

How does Mallory Weiss tear present?

Answer 4

Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting. Melena is rare. Usually ceases spontaneously

Question 5

How does gastric cancer present?

Answer 5

May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage

Question 6

How does gastric ulcer present?

Answer 6

Small low low-volume bleeds are more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis.

Question 7

Which gastric ulcers are likely to perforate?

Answer 7

Anterior ulcers

Question 8

Which gastric ulcers are prone to bleeding?

Answer 8

Posterior ulcers

Question 9

What is dieulafoy lesion?

Answer 9

Large turtous submucosaucosal artery casing bleeding. Didficult to detect endoscopically.

Question 10

What are the duodenal causes of bleedingding?

Answer 10

Posterioriro duodenal ulcer
Aorta-enteric fitsula

Question 11

What is diffuse erosive gastritis?

Answer 11

Diffusive Erosive gastritis is erosion and stomach ulcers throughout stomach caused by alcohol, NSAIDs and stress. Presents with epigastric discomfort and haematemesis

Question 12

What is the risk for aort-enteric fistula?

Answer 12

In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.

Question 14

What are the features of Glasgow blatchford score?

Answer 14

High urea levels
Hb low
Systolic blood pressure low
Tachycardia

Question 15

What scores highly in Glasgow blatchford?

Answer 15

Urea over 25

->urea over 6.5 is at least 2 points
SB less than 90
Liver disease/cardiac/failure

Question 16

What is used for management I of bleeding in those taking warfarin?

Answer 16

Prothrombin complex concentrate

Question 17

What is offered for transfusion for those with low fibrinogen level?

Answer 17

Fresh frozen plasma
-> offered if PTT time greater than 1.5x

Question 18

What should be avoided before endoscopy?

Answer 18

PPIs

Question 19

What is the management of variceal bleeding?

Answer 19

terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices

Question 20

What should be offered for patients with uncontrolled bleeding?

Answer 20

TIPS

Question 21

Rockall score 3 points? l

Answer 21

Liver disease cardiac disease or metastatic disease

Question 22

Rockall score 2 points?

Answer 22

Age over 80
Hypotension
Any comorbidities except liver, renal and metastasis
Malignancy of upper GI
Stigmata of bleed

Question 23

What is the stigmata of major bleed?

Answer 23

Blood in upper GI tract
Adherent tract
Spurting vessel

Question 24

What is ineffective in Haematemesis caused by gastric ulcer?

Answer 24

Terlipressin

Question 25

How to manage Haematemesis caused by ulcer?

Answer 25

Bleeding will occur with posterior ulcer, likely from a major artery therefore it requires urgent: Laparotomy Surgical exploration IV PPI

Question 26

What should be given prior to endoscopy?

Answer 26

Antibiotics and Terlipressin

Question 27

What is first line for uncontrolled variceal haemorrhage?

Answer 27

The Sengstaken-Blakemore tube is a specialised double-balloon tamponade device designed to arrest an uncontrolled variceal haemorrhage

Question 28

What are indications for insertion of songs taken-blakemore tube?

Answer 28

Acute, life-threatening oesophageal or gastric variceal bleeding that is refractory to medical management, including endoscopic intervention and pharmacotherapy such as vasoconstrictors

Question 29

What is second line for uncontrolled variceal bleeding?

Answer 29

TIPS -> associated with an elevated risk of precipitating hepatic encephalopathy

Question 30

What should be done to reduce mortality in patients with liver cirrhosis?

Answer 30

Prophylactic IV antibiotics like quinones such as ceftriazone and Terlipressin

Question 31

What should be given for uncontrolled haemorrhage?

Answer 31

Sengstaken-Blakemore tube-> temporary, emergency rescue intervention to stop acute, life-threatening upper gastrointestinal bleeding from esophageal varices. It applies direct tamponade pressure via inflatable gastric and esophageal balloons, typically used when endoscopic therapy fails or is unavailable This should be done before TIPS

Question 32

How to differentiate a bleeding peptic ulcer and oesopageal varices?

Answer 32

Bleeding peptic ulcer: history of burning epigastric pain combined with a history of NSAID use, with melee a and syncope Bleeding oesophageal varices: past medical history of liver cirrhosis and portal hypertension, in a patient who presents with haematemesis.

Question 33

What is a feature of stools?

Answer 33

Tarry stools that are black

Question 34

How to differentiate history of perforated and bleeding peptic ulcer?

Answer 34

A perforated peptic ulcer would present with signs and symptoms of peritonitis as contents from the gastrointestinal system will enter the peritoneal cavity. The signs and symptoms that would be seen include diffuse abdominal pain, abdominal distension, rigidity, and guarding

Question 35

What causes sudden haemodynamically instability with normal abdominal exam and low HB and High urea?

Answer 35

Upper GI bleed-> perforated is more likely to cause extreme changes

Question 36

What causes small volume of fresh blood in vomit ith history of GERD?

Answer 36

Oesopjagitis

Question 37

What causes Haematemesis with history of dyspepsia?

Answer 37

Gastric cancer

Question 38

What causes acute Haematemesis with no prodromal features?

Answer 38

Dieulafoy lesion which will have normal endoscopy de to difficulty visualising AV malformation

Question 39

What causes Haematemesis with history of previous abomdinal aortic surgery?

Answer 39

Aorta-enteric fistula

Question 40

Which score is used at first assessment?

Answer 40

Glasgow-blatchford for urea, HB, SBP and other features

Question 41

When to give platelet transfusion in Haematemesis?

Answer 41

platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre

Question 42

When to give fresh frozen plasma transfusion in Haematemesis?

Answer 42

patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal

Question 43

When to give prothrombin complex concentrate transfusion in Haematemesis?

Answer 43

Warfarin use and active bleeding

Question 44

which investigation must be done with massive upper GI bleed?

Answer 44

all patients should have endoscopy within 24 hours

Question 45

What is TIPS used for?

Answer 45

TIPS is used only for oesophageal varices bleeding last line

Question 46

What should be done for upper GI bleeding if band ligation does not resolve bleeding?

Answer 46

Refer to general surgery

Question 47

What is given for short term haemostasis in variceal bleeding!

Answer 47

Balloon t,aponade

Question 48

How to control upper GI bleeding in stable patient?

Answer 48

Resuscitate and activate the major haemorrhage protocol for any significant bleed Resuscitate with IV fluids or blood if Hb below 70 Correct coagulopathy

Question 49

What to do in severe upper GI bleeding!

Answer 49

Two attempts of endoscopy intervenfion

Question 50

What to do in suspected variceal bleed?

Answer 50

terlipressin and prophylactic antibiotics

Question 51

How to treat non variceal upper GI bleeding in.

Answer 51

Non-variceal bleeds can be treated mechanically (e.g. clipping), with thermal coagulation or with fibrin or thrombin (plus adrenaline

Question 52

How to manage oesophageal variceal bleed?

Answer 52

Band ligation

Question 53

How to treat gastric variceal bleed?

Answer 53

N-butyl-2-cyanoacrylate injections (sclerotherapy

Question 54

When to give PPI in upper GI bleeding!

Answer 54

Only give after endoscopy showing a non-variceal UGIB with stigmata of recent haemorrhage

Question 55

What to do if bleeding persists after two endoscopy attempts.

Answer 55

Sengstaken-Blakemore tube insertion (a bridging therapy) Escalate to a transjugular intrahepatic portosystemic shunt if it continues (a definitive treatment to reduce portal pressure in appropriate patients