Upper GI Bleeding

Question 1

Upper GI Bleeding Aetiology

Answer 1

• Endoscopy does not reveal cause in approximately 20% of patients with UGIB
• Most common causes are peptic ulcer and oesophagi-gastric varices
• Oesophagitis, gastritis/erosions, erosive duodenitis, malignancy, Mallory-Weiss

Question 2

Upper GI Bleeding Risk Factors

Answer 2

• Alcohol abuse
• Chronic renal failure (anaemia, thrombocytopenia and frequent heparin use in dialysis)
• NSAIDs
• Age
• Low socio-economic class

Risk factors for rebleeding

• Age>60
• Signs of shock on admission
• Pulsatile haemorrhage
• CV disease

Question 3

Upper GI Bleeding Assessment

Answer 3

• Bleeding severity can be assessed by extent of blood loss and degree of shock
• Abdo pain
• Bleeding (haematemesis, coffee ground vomit, melaena, haematochezia)
• Loss of blood, shock, syncope, presyncope
• Dyspepsia, weight loss, jaundice
• Retching

Examination

• Pallor and signs of anaemia
• Pulse and BP
• Postural hypotension
• Other signs of shock

Question 4

Upper GI Bleeding Ix

Answer 4

• Endoscopy is primary investigation
• Should be undertaken within 24hours
• FBC; measure haemoglobin serially
• Crossmatch
• Coagulation (consumptive coagulopathy can occur
• LFTs
• Renal function (serum urea nitrogen:creatinine ratio increases likelihood of UGIB

Imaging

• CXR
• Erect and supine abdominal x-ray
• CT scan if endoscopy inconclusive

Question 5

Upper GI Bleeding Admission

Answer 5

• Aged>60
• Witnessed haematemesis or haematochezia
• Haemodynamic disturbance
• Liver disease or known varices

Question 6

Upper GI Bleeding Management

Answer 6

• Prompt volume replacement, early and aggressive reduces mortality
• Major haemorrhage protocol blood, platelets and clotting factors
• Decision on transfusion based on full clinical picture
• Platelet transfusion if actively bleeding or thrombocytopenic
• Prothrombin complex for patients on warfarin

Question 7

Upper GI Bleeding Risk Assessment

Answer 7

• Blatchford and Rockall
• Blatchford is pre-endoscopy, anyone with more than 0 requires intervention
• Rockall score post-endoscopy for risk of re-bleeding, if <3 can usually be discharged

Question 8

Upper GI Bleeding Management of Variceal and Non-Variceal Bleeding

Answer 8

Variceal

• Terlipressin
• Prophylactic antibiotics

Non-Variceal
-Endoscopy

Question 9

Upper GI Bleeding Management Post-Endoscopy

Answer 9

• Test for H.pylori
• Treat if positive
• Three further weeks of ulcer healing therapy