Upper GI Bleed

Question 1

Name the potential causes of an upper GI bleed

Answer 1

• Duodenal ulcer
• Gastric erosions/ ulcer
• Varices/ Mallory-Weiss tear
• Oesophagitis
• Erosive duodenitis
• Cancer
• stomal ulcer/ oesophageal ulcer

Question 2

How do you manage a patient who presents with an Upper GI bleed?

Answer 2

• medical emergency
  => ABCDE

Airway protection
Oxygen
IV access
Fluids

Question 3

To assess the severity of a haemorrhage, doctors can use the “100 Rule”. What does this mean?

Answer 3

The 100 rule identifies the group with poor prognosis

systolic BP < 100mmHg
pulse > 100/min
Hb < 100 g/l
age > 60
comorbid disease
postural drop in blood pressure

Question 4

What score is used in NHS Tayside to determine the management of patients with an Upper GI bleed?

Answer 4

Blatchford score

This takes into account:

• Blood urea level
• Hb
• Systolic BP

other markers are HR, melaena, syncope, and pre-existing conditions

Question 5

What Blatchford scores indicate a mild, intermediate or high risk?

Answer 5

MILD = 0-1
INTERMEDIATE = 2-5
SEVERE = >5

Question 6

How can acutely bleeding peptic ulcers be treated?

Answer 6

• Endoscopic treatment (high risk ulcers)
• Acid suppression (IV omeprazole)
• Interventional radiology
• Surgery

ALSO (H. pylori eradication - secondary prevention)

Question 7

What can be used during endoscopic treatment of a peptic ulcer to stop the bleeding?

Answer 7

• Injection (adrenaline)
• Heater probe coagulation
• Clips
• Haemospray

Question 8

Describe how haemospray works to stop a peptic ulcer from bleeding

Answer 8

When Haemospray comes in contact with blood:
- powder absorbs water
- acts both cohesively and adhesively
=> mechanical barrier over the bleeding site

Question 9

Describe what happens if a peptic ulcer rebleeds after achieving haemostasis?

Answer 9

• Omeprazole is still given IV
• Endoscopic therapy is re-attempted
• if bleeding continues => Interventional radiology or surgery

Question 10

If a peptic ulcer bleed is unable to be contained by endoscopic therapy, what is the next step?

Answer 10

Interventional radiology or surgery

Question 11

In what patients should you expect that an upper GI bleed may be from oesophageal varices?

Answer 11

Known Hx of:

• cirrhosis
• chronic alcohol excess
• chronic viral hepatitis infection
• metabolic or autoimmune liver disease
• intra-abdominal sepsis/surgery

O/E

• spider naevi
• palmar erythema
• ascites
• jaundice

Question 12

How is haemostasis achieved in patients with bleeding varices?

Answer 12

• Terlipressin (vasopressin analogue)
• Endoscopic variceal ligation (banding)
• Sclerotherapy
• Sengstaken-Blakemore balloon
• TIPS

Question 13

What is Terlipressin used for in bleeding varices?

Answer 13

• It is a vasopressin prodrug
• Works predominantly to vasoconstrict the splanchnic vessels
• Has a beneficial effect on renal perfusion unlike other drugs of its type

Question 14

Describe how Endoscopic variceal ligation (EVL) works

Answer 14

• make a little outpouching of the varices into the lumen

- band the bottom of this outpouching to prevent bleeding

Question 15

What is sclerotherapy?

Answer 15

• drug injected into the variceal vessels to make them shrink

Question 16

When is a TIPS procedure usually used?

Answer 16

When a patient with known cirrhosis has uncontrollable bleeding gastric varices

Question 17

How is a patient with bleeding varices initially managed?

Answer 17

• resuscitation
• antibiotics
• terlipressin + early gastroscopy + EVL

Question 18

If initial management (terlipressin and EVL) is enough to stop the variceal bleed, how is the patient managed long term?

Answer 18

Propranolol and Banding programme

Question 19

If initial management (terlipressin and EVL) is NOT enough to stop the variceal bleed, how is the patient managed?

Answer 19

• another attempt at EVL or insertion of a Sengstaken-Blakemore balloon
• if this fails to stop the bleed, a TIPS procedure is carried out
• If the hepatic function is poor, a liver transplant may be more appropriate