Upper GI Bleed

Question 1

What does an upper GI bleed indicate?

Answer 1

A medical emergency indicating a bleed from the oesophagus, stomach or duodenum

Question 2

Causes of upper GI bleed?

Answer 2

1) Oesophageal varices
2) Mallory-Weiss tear (tear of oesophageal mucous membrane)
3) ulcer - stomach or duodenum
4) cancer - stomach or duoedenum

Question 3

Presentation of an upper GI bleed?

Answer 3

1) Haematemesis - vomiting blood
2) ‘coffee ground vomit’ - digested blood
3) Melaena - digested blood (black, greasy, offensive)
4) Haemodynamic instability (tachycardia, hypotensive)

Question 4

Additional symptoms related to underlying pathology?

Answer 4

• peptic ulcer –> epigastric pain, dyspepsia

- oesophageal varices –> jaundice, ascites

Question 5

Scoring system for suspected upper GI bleed?

Answer 5

Glasgow-Blatchford Score - establishes risk of having an upper GI bleed at initial presentation

Question 6

What score indicates high risk (Glasgow-Blatchford score)?

Answer 6

Anything over 0

Question 7

What features does the Glasgow-Blatchford score consider?

Answer 7

• Drop in Hb
• Rise in urea (digested in GI tract, reabsorbed as urea0
• BP, HR
• Mealena
• Syncope

Question 8

What score is used in a patient who has already had an endoscopy?

Answer 8

Rockall Score - provides % risk of rebleed + mortality

Question 9

Risk factors + clinical features considered in Rockall score?

Answer 9

• Age
• Features of shock (BP, HR)
• Co-morbidities
• Cause of bleed
• Endoscopic stigmata or recent haemorrhage (clots, visible bleeding vessels)

Question 10

Management of upper GI bleed?

Answer 10

ABATED!

• ABCDE approach to resus
• Bloods
• Access (2 large bore cannulas)
• Transfuse
• Endoscopy (urgent, within 24hrs)
• Drugs (stop anticoagulants, NSAIDs)

Question 11

Bloods to arrange (5)?

Answer 11

1) Haemoglobin (FBC)
2) Urea (U&E’s)
3) Coagulation (INR, FBC for platelets)
4) Liver disease (LFTs)
5) Crossmatch 2 units of blood

Question 12

Outline transfusions (based on presentation)?

Answer 12

• Massive haemorrhage –> blood, platelets + FFP (clotting factors)
• Active bleed + platelets <50 –> Platelets
• Active bleed + on warfarin –> PT complex concentrate

Question 13

Additional management if patient present with oesophageal varices?

Answer 13

1) Terlipressin

2) Prophylactic broad spectrum abx

Question 14

Definitive management?

Answer 14

OGD - oesophagogastroduoedenoscopy

Question 15

Would you use a PPI prior to endoscopy?

Answer 15

NICE recommends against the use

Question 16

Management of Mallory-Weiss tear?

Answer 16

Usually resolves spontaneously

Question 17

What would you give to a patient presenting with oesophageal varices prior to endoscopy?

Answer 17

Terlipressin + prophylactic abx (piperacillin/tazobactam)

Question 18

How many points is a patient with Ischaemic Heart Disease get on the Rockall score?

Answer 18

2

Question 19

Secondary prophylaxis of oesophageal varices?

Answer 19

Propanolol

Question 20

When would you suspect Mallory-Weiss tear?

Answer 20

History of forceful wretching (bulimia vs. alcohol bringe)

Question 21

What do you expect Hb levels to do after an acute bleed and before fluid resus?

Answer 21

Unchanged from baseline - measures free Hb in blood so loss of whole blood will not change conc