Upper GI bleeding

Question 1

What defines upper GI bleeding?

Answer 1

Bleeding originating proximal to the ligament of Treitz.

Typically presents with melena or hematemesis, distinguishing it from lower GI bleeding.

Question 2

What is melena, and what causes it?

Answer 2

Black, tarry, sticky, malodorous stools due to oxidized hemoglobin from upper GI bleeding.

Requires 100-200 cc of blood loss to manifest.

Question 3

What is the significance of occult blood in stool?

Answer 3

Indicates as little as 3 cc of blood loss, detectable only by testing.

Less severe than melena but may suggest early or chronic bleeding.

Question 4

What are common symptoms of upper GI bleeding?

Answer 4

Melena, lightheadedness, fatigability, epigastric pain, or hematemesis.

Symptoms reflect blood loss and underlying pathology (e.g., peptic ulcer).

Question 5

What physical exam findings suggest upper GI bleeding?

Answer 5

Orthostatic hypotension, tachycardia, epigastric tenderness, black tarry stool on rectal exam.

Orthostatic changes indicate significant blood loss (>10-15% blood volume).

Question 6

What is the most common cause of non-variceal upper GI bleeding?

Answer 6

Peptic ulcers (28-59%).

Includes duodenal (17-37%) and gastric (11-24%) ulcers.

Question 7

What is the prevalence of mucosal erosive disease in upper GI bleeding?

Answer 7

1-47%.

Affects esophagus, stomach, or duodenum, often due to NSAIDs or alcohol.

Question 8

What is Mallory-Weiss syndrome?

Answer 8

Mucosal tear at the gastroesophageal junction causing 4-7% of upper GI bleeds.

Often associated with vomiting or retching.

Question 9

What is the role of malignancy in upper GI bleeding?

Answer 9

Accounts for 2-4% of cases.

May involve gastric or esophageal cancers.

Question 10

What are variceal causes of upper GI bleeding?

Answer 10

Portal hypertension (e.g., from cirrhosis).

Less common than non-variceal causes but high mortality if untreated.

Question 11

What lab findings are typical in upper GI bleeding?

Answer 11

Low hemoglobin (e.g., 9 g/dL), low hematocrit (e.g., 27%), elevated BUN (e.g., 45 mg/dL).

Elevated BUN:creatinine ratio (>20:1) due to blood protein absorption.

Question 12

Why is BUN elevated in upper GI bleeding?

Answer 12

Digestion of blood proteins in the GI tract increases urea production.

A key diagnostic clue, especially with normal creatinine.

Question 13

What is the first step in managing upper GI bleeding?

Answer 13

ABC (Airway, Breathing, Circulation): Stabilize with IV fluids and transfusions.

Prioritize hemodynamic stability before diagnostic or therapeutic steps.

Question 14

What is the target hemoglobin for transfusion in upper GI bleeding?

Answer 14

7-9 g/dL.

Avoid over-transfusion to reduce rebleeding risk.

Question 15

What is the primary diagnostic tool for upper GI bleeding?

Answer 15

Endoscopy.

Identifies bleeding source and allows therapeutic intervention.

Question 16

What are therapeutic options during endoscopy for upper GI bleeding?

Answer 16

Hemostatic clips, epinephrine injection, thermal coagulation, sclerosing agents (e.g., ethanol).

Combination therapy (e.g., injection + coagulation) is often used.

Question 17

When should endoscopy be performed in upper GI bleeding?

Answer 17

Within 24 hours; <12 hours for high-risk cases (e.g., persistent instability).

Timing depends on hemodynamic status and bleeding severity.

Question 18

What are high-risk features requiring very early endoscopy (<12 hours)?

Answer 18

Persistent hemodynamic instability, in-hospital hematemesis, anticoagulation issues.

Source: ESGE Guideline (2015).

Question 19

What is the role of proton pump inhibitors (PPIs) in upper GI bleeding?

Answer 19

High-dose IV PPI (80 mg bolus, 8 mg/hr for 72 hours) reduces rebleeding risk.

Stabilizes clots by increasing gastric pH.

Question 20

What endoscopic findings require intervention in upper GI bleeding?

Answer 20

Actively bleeding ulcer, ulcer with clot, or ulcer with visible vessel.

Clean-based ulcers have low rebleeding risk.

Question 21

What happens if endoscopic therapy fails to control bleeding?

Answer 21

Repeat endoscopic therapy or proceed to surgery.

Surgery is a last resort after medical and endoscopic failure.

Question 22

What are absolute indications for surgery in upper GI bleeding?

Answer 22

Persistent blood loss refractory to endoscopy, transfusion >6 units RBC.

Indicates severe, uncontrolled bleeding.

Question 23

What are relative indications for surgery in upper GI bleeding?

Answer 23

Elderly, shock with recurrent hemorrhage, severe comorbidities, suspected malignancy.

Guides surgical decision-making in complex cases.

Question 24

What surgical technique is used for bleeding duodenal ulcers?

Answer 24

Duodenotomy with suture ligation (four-quadrant suture).

Direct pressure may be applied initially to control bleeding.

Question 25

What surgical options are available for non-malignant gastric ulcers?

Answer 25

Gastrotomy with suture ligation. ## Footnote Aimed at controlling bleeding at the ulcer site.

Question 26

What surgical options are used for malignant gastric ulcers?

Answer 26

Simple excision, distal gastrectomy, or subtotal gastrectomy. ## Footnote Extent of resection depends on malignancy characteristics.

Question 27

What is the Glasgow-Blatchford Score used for?

Answer 27

Risk stratification for upper GI bleeding to guide need for intervention. ## Footnote Based on BUN, hemoglobin, BP, heart rate, melena, syncope, hepatic disease, cardiac failure.

Question 28

What Glasgow-Blatchford Score threshold indicates high risk?

Answer 28

Score ≥6. ## Footnote Suggests need for urgent endoscopy or hospitalization.

Question 29

What is the Rockall Score, and what does it predict?

Answer 29

Predicts rebleeding and mortality risk using age, shock, comorbidity, diagnosis, and signs of recent hemorrhage. ## Footnote Score >5 indicates >24.1% rebleeding risk, >10.8% mortality risk.

Question 30

What are the pre-endoscopy variables in the Rockall Score?

Answer 30

Age, shock (BP, pulse), comorbidity. ## Footnote Used to assess risk before diagnostic confirmation.

Question 31

What does a Rockall Score ≤5 indicate?

Answer 31

Rebleeding risk <14.1%, mortality risk <5.3%. ## Footnote Suggests lower-risk patients who may not need urgent intervention.

Question 32

What is the role of H. pylori in upper GI bleeding?

Answer 32

Major cause of peptic ulcers; eradication reduces recurrence. ## Footnote Test via urea breath test, stool antigen, or biopsy.

Question 33

How is H. pylori treated in the context of upper GI bleeding?

Answer 33

Antibiotics (e.g., clarithromycin, amoxicillin) plus PPI. ## Footnote Triple or quadruple therapy is standard, depending on resistance.

Question 34

What are key risk factors for peptic ulcer disease?

Answer 34

H. pylori, NSAIDs, alcohol, smoking, stress (rarely Zollinger-Ellison syndrome). ## Footnote High-yield for exams due to preventable/treatable causes.

Question 35

What imaging is typically used in upper GI bleeding?

Answer 35

Chest X-ray and KUB (kidney, ureter, bladder) if needed; often unremarkable. ## Footnote Imaging rules out complications (e.g., perforation) but is secondary to endoscopy.

Question 36

What is the significance of a normal PT/PTT in upper GI bleeding?

Answer 36

Indicates no underlying coagulopathy contributing to bleeding. ## Footnote Important to assess before invasive procedures like endoscopy.

Question 37

What is the key to preventing recurrent upper GI bleeding?

Answer 37

Eradicate H. pylori, discontinue NSAIDs, and use maintenance PPI therapy. ## Footnote Lifestyle changes (e.g., reduce alcohol, smoking) also critical.

Question 38

What are high-yield exam points for upper GI bleeding management?

Answer 38

ABC resuscitation, high-dose PPI, early endoscopy, H. pylori eradication, surgery as last resort. ## Footnote Systematic approach reduces mortality and rebleeding risk.

Question 39

What is the role of intravascular resuscitation in upper GI bleeding?

Answer 39

Restores hemodynamic stability using IV fluids and RBC transfusions. ## Footnote Essential first step in hemodynamically unstable patients.

Question 40

What is a clean-based ulcer, and what is its significance?

Answer 40

Ulcer with no clot, vessel, or active bleeding; low risk of rebleeding. ## Footnote May allow early discharge after PPI therapy.