Upper GI bleeding

Question 1

What are the common causes of upper GI bleeding?

Answer 1

Peptic ulcers
Mallory-Weiss tear
Oesophageal varices
Gastritis/ gastric erosions
Drugs (NSAIDs, aspirin, steroids, thrombolytics, anticoagulants)
Oesophagitis
Duodenitis
Malignancy
No obvious cause

Question 2

What are the rare causes of upper GI bleeding?

Answer 2

Bleeding disorders
Portal hypertensive gastropathy
Aorto-enteric fistula (following aortic graft repair)
Angiodysplasia
Haemobilia
Dieulafoy lesion (rupture of unusually big arteriole, e.g. in fundus of stomach)
Meckel's diverticulum
Peutz-Jeghers' syndrome
Osler-Weber-Rendu syndrome

Question 3

What is haematemesis?

Answer 3

Vomiting of blood.
It may be bright red or look like coffee grounds.
Indicates upper GI bleeding.

Question 4

What is melaena?

Answer 4

Black motions (stool), often like tar.
Characteristic smell of altered blood.
Indicates upper GI bleeding.

Question 5

If haematemesis or melaena is reported, what questions should be asked specifically in the history?

Answer 5

Past GI bleeds
Dyspepsia/ known ulcers
Known liver disease or oesophageal varices
Dysphagia
Vomiting
Weight loss
Check drugs and alcohol use
Is there serious comorbidity (bad prognosis), e.g. cardiovascular disease, respiratory disease, hepatic or renal impairment, or malignancy?

Question 6

What should you look for when examining a patient with haematemesis or melaena?

Answer 6

Signs of chronic liver disease.
Do a PR to check for melaena.
Is the patient shocked?
Peripherally cool/clammy; capillary refill time >2s; urine output <0.5mL/kg/h.
Low GCS (tricky to assess in decompensated liver disease) or encephalopathy.
Tachycardia (pulse >100bpm).
Systolic BP <100mmHg; postural drop >20mmHg.
Calculate the Rockall score.

Question 7

What is the acute management of an upper GI bleed?

Answer 7

Start by protecting the airway and giving high-flow O2.
Insert 2 large-bore (14-16G) IV cannula and take blood for FBC (early Hb may be normal because haemodilution has not yet taken place), U&E (raised urea out of proportion to creatinine indicative of massive blood meal), LFT, clotting, and crossmatch.
Give IV fluids to restore intravascular volume while waiting for cross-matched blood.
If haemodynamically deteriorating despite fluid resuscitation, give group O Rh-ve blood.
Avoid saline if cirrhotic/varices.
Insert a urinary catheter and monitor hourly urine output.
Organise a CXR, ECG, and check ABG.
Consider a CVP line to monitor and guide fluid replacement.
Transfuse (with crossmatched blood if needed) if significant Hb drop (<70g/L).
Correct clotting abnormalities (vitamin K, FFP, platelets).
If suspicion of varices then give terlipressin IV e.g. 1-2mg/6h for <3d; relative risk of death reduced by 34%. Initiate broad-spectrum IV antibiotic cover.
Monitor pulse, BP, and CVP (keep >5cmH2O) at least hourly until stable.
Arrange an urgent endoscopy.
If endoscopic control fails, surgery or emergency mesenteric angiography/ embolisation may be needed.
For uncontrolled oesophageal variceal bleeding, a Sengstaken-Blakemore tube may compress the varices.

Question 8

What is the further (non-acute) management of an upper GI bleed?

Answer 8

Anatomy is important in assessing risk of rebleeding.
Posterior DUs are highest risk as they are nearest to the gastroduodenal artery.
Re-examine after 4h and consider the need for FFP if >4 units transfused.
Hourly pulse, BP, CVP, urine output (4hrly if haemodynamically stable may be OK).
Transfuse to keep Hb >70g/L; ensure a current valid group & save sample.
Check FBC, U&E, LFT, and clotting daily.
Keep nil by mouth if at high rebleed risk- ask endoscopist.

Question 9

What is Rockall risk scoring?

Answer 9

For upper GI bleeds.
Initial Rockall score is based on pre-endoscopy criteria, which are added to post-endoscopy criteria for final score predicting risk of rebleeding and death.

Question 10

What are the pre-endoscopy criteria for the Rockall score?

Answer 10

Age: 0 = <60yrs; 1 = 60-79yrs; 2 = >80yrs.
Shock (systolic BP and pulse rate): 0 = BP >100mmHg, pulse <100bpm; 1 = BP >100mmHg, pulse >100bpm; 2 = BP <100mmHg.
Comorbidity: 0 = nil major; 1 = heart failure, ischaemic heart disease; 2 = renal failure, liver failure; 3 = metastases.

Question 11

What are the post-endoscopy criteria for the Rockall score?

Answer 11

Diagnosis: 0 = Mallory Weiss tear, no lesion, no sign of recent bleeding; 1 = all other diagnoses; 2 = upper GI malignancy.
Signs of recent haemorrhage on endoscopy: 0 = none, or dark red spot; 2 = blood in upper GI tract, adherent clot, visible vessel.

Question 12

What is the Glasgow Blatchford score (GBS)?

Answer 12

Used pre-endoscopy to identify patients at low risk of requiring intervention. If GBS = 0, admission can be avoided- i.e. Hb >130g/L (or >120g/L if female); systolic BP >110mmHg; pulse <100bpm; urea <6.5mmol/L; no melaena or syncope + no past/present liver disease or heart failure.

Question 13

What is classified as a high risk peptic ulcer bleed?

Answer 13

Active bleeding, adherent clot, or non-bleeding visible vessel upon endoscopy.

Question 14

How is a high risk peptic ulcer bleed managed?

Answer 14

Achieve endoscopic haemostasis: 2 of clips, cautery, adrenaline.
Admit to monitored bed.
Start PPI (e.g. omeprazole 40mg/12h IV/PO).
If haemodynamically stable start oral intake of clear liquids 6h after endoscopy.
Treat if positive for H. pylori.

Question 15

What is classified as a low risk peptic ulcer bleed?

Answer 15

Flat, pigmented spot or clean base upon endoscopy.

Question 16

How is a low risk peptic ulcer bleed managed?

Answer 16

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 17

What are the characteristics of an upper GI bleed from gastro-oesophageal varices?

Answer 17

Submucosal venous dilatation secondary to raised portal pressures (may not have documented liver disease- suspect varices if alcohol history).
Bleed can be brisk, particularly if underlying coagulopathy secondary to loss of hepatic synthesis of clotting factors.

Question 18

What are the causes of portal hypertension?

Answer 18

Pre-hepatic: Thrombosis (portal or splenic vein).
Hepatic: Cirrhosis (80% in UK); Schistosomiasis (commonest worldwide); Sarcoid; Myeloproliferative diseases; Congenital hepatic fibrosis.
Post-hepatic: Budd-Chiari syndrome; Right heart failure; Constrictive pericarditis; Veno-occlusive disease.

Question 19

What are the risk factors for vatical bleeds?

Answer 19

Increased portal pressure
Variceal size
Endoscopic features of the variceal wall
Advanced liver disease

Question 20

How are upper GI bleeds from gastro-oesophageal varices managed?

Answer 20

Endoscopic banding (oesophageal) or sclerotherapy (gastric).
Primary prophylaxis: ~30% of cirrhotics with varices bleed vs. ~15% with non-selective beta-blockade (propranolol 20-40mg/12h PO) or repeat endoscopic banding.
Secondary prophylaxis: after a first variceal bleed, 60% rebleed within 1yr. Use banding and non-selective beta-blocker; transjugular intrahepatic porto-systemic shunt (TIPS) for resistant varices.