Common upper GI bleed exam questions for medical finals, OSCEs and MRCP PACES
What are the common causes of upper GI bleeds?
- Peptic ulcer disease – oesophageal, gastric or duodenal ulcers
- Prevalence 4% of the population
- Due to H. pylori, NSAID use, alcohol, steroid use, Zollinger-Ellison syndrome (gastrin-secreting tumour causing multiple ulcers)
- Oesophagitis and gastroduodenal erosions (15%)
- Due to aspirin, other NSAIDS, steroids etc.
- Oesophageal varices
- Due to portal hypertension, usually associated with chronic liver disease
- Portal hypertensive gastropathy
- Mallory-Weiss tears
- Secondary to prolonged vomiting
- Dieulafoy’s lesion
- Tortuous arteriole usually upper part of lesser curve, bleeding occurs through a tiny defect.
- Upper GI malignancy
- Vascular malformations
- Aorto-enteric fistula (commonest at approx 5 years post-surgery. Approx 2% risk)
What is the initial resuscitation management of upper GI bleed?
- A – manage airway and consider need for intubation/airway adjunct or suctioning
- B – give oxygen to maintain sats > 96%
- C –
- BP, HR
- Large-bore IV access x 2
- VBG to assess Hb, acidosis, lactate
- Send lab bloods for FBC, U+Es, clotting, X-match (2-4 units usually)
- IV fluid resuscitation (crystalloid is fine acutely)
- D – AVPU, check glucose level
- E – ?peritonitic abdomen
What are the common scoring systems in upper GI bleeds?
- Age, Shock, Co-morbidities
- Diagnosis and stigmata after endoscopy
- Scores below 2 have a very low mortality
- Scores 8 or higher have a mortality of 40%+
- Risk stratify – predicts the need for hospital-based intervention
- Urea, Hb, Systolic BP
- Other: pulse, melaena, syncope, hepatic disease, cardiac failure
- Use acutely but not as good as Rockall in predicting overall mortality
- Score 0 = home
- Score >0 = endoscopy
- Score >5 (6 and up) = same day endoscopy