upper GI bleeds

Question 1

commonest causes of upper GI bleeding

Answer 1

oesophageal varices
peptic ulcer disease

Question 2

upper GI bleed presentation

Answer 2

haematemesis - fresh or coffee ground
malena - black/tarry
raised urea

features of cause
- varices - signs of chronic liver disease
- peptic ulcer - abdo pain

Question 3

Risk assessment done in upper GI bleeds

Answer 3

Glasgow-Blatchford score
- done first, decides whether outpatient or not

Rockall score
- used after endoscopy
- risk of rebleed + mortality

Question 4

blood product given to bleeding patient taking warfarin

Answer 4

prothrombin complex concentrate

Question 5

management of upper GI bleeds

Answer 5

resuscitation - ABC, IV access, fresh frozen plasma

endoscopy
- all should have within 24hrs

non-variceal - DO NOT give PPI before endoscopy

Question 6

management of variceal bleeding

Answer 6

terlipressin + prophylactic Abx - before endoscopy

oseophageal varices = band ligation
gastric varices = injections of N-butyl-2cyanoacrylate

uncontrolled haem = Sengstaken-Blakemore tube

if not controlled by above = transjugular intrahepatic portosystemic shunts (TIPS)

Question 7

duodenal ulcers

Answer 7

commoner
pain when HUNGRY, RELIEVED by eating
may arode to gastroduodenal artery

Question 8

gastric ulcers

Answer 8

pain worsened by eating

Question 9

risk factors for peptic ulcers

Answer 9

h.pylori

drugs - NSAIDs, SSRIs, steroids, bisphosphonates

zollinger-ellison syndrome - rare, excessive levels of gastrin from tumour

Question 10

investigations in peptic ulcer disease (uncomplicated)

Answer 10

H.pylori –> urea breath test

or stool antigen

Question 11

management of uncomplicated peptic ulcer disease

Answer 11

H.Pylori neg = PPIs until healed

H.pylori pos = PPI + amoxicillin + (clarithromycin OR metronidazole)

(if pen allerg - PPI + clar + met)

Question 12

perforated peptic ulcer disease presentation

Answer 12

develop suddenly -
- epigastric pain, becoming genralised
- syncope

Question 13

perforated peptic ulcer disease investigation

Answer 13

upright “erect” chest x-ray

= free air under diaphragm
(diagnosis largely clinical)

Question 14

complication ofTransjugular Intrahepatic Portosystemic Shunt (TIPSS) procedure

Answer 14

exacerbation of hepatic encephalopathy
-> inadequate metabolism of nitrogenous waste products such as ammonia by liver

(connects hepatic to portal vein)

Question 15

prophylaxis of variceal haemorrhage

Answer 15

propranolol

endoscopic variceal band ligation
- PPI coverage given
- performed at 2wkly until all eradicated

Question 16

H. Pylori

Answer 16

gram neg bacteria
- principally peptic ulcer disease
- role in GORD unclear, dont give eradication tx

Question 17

2 main mechanisms H.Pylori survives the acidic environment

Answer 17

chemotaxis aways from low pH areas, uses flagella to burrow into mucous lining to reach the epithelial cells underneath

secretes urease -> converted to NH3 -> alkalinisation of environment -> increased bacterial survivial

Question 18

H.pylori associations

Answer 18

peptic ulcer disease
- 95% duodenal
- 75% of gastric

gastric cancer
B cell lymphoma of MALT tissue - eradication of H.pylori causes regression in 80%

atrophic gastritis

Question 19

H.pylori eradication tx

Answer 19

7 days - PPI + amoxicillin + (clarithromycin OR metronidazole)

• if ongoing sx - PPI + amox + which ever one wasnt used
• if pen all - PPI + met + clarithro