Acute Gastrointestinal Bleeding

Question 1

What defines upper GI bleeding?

Answer 1

Bleeding from oesophagus, stomach or duodenum

Proximal to ligament of Trietz

Question 2

What defines lower GI bleeding?

Answer 2

Bleeding distal to duodenum

Distal to ligament of Trietz

Question 3

What are the signs of upper GI bleeding?

Answer 3

Haematemesis
Melaena
Elevated urea
Dyspepsia, reflux, epigastric pain
NSAIDs use

Question 4

What are the signs of lower GI bleeding?

Answer 4

Fresh blood/clots
Magenta stools
Normal urea
Typically painless
More common in older people

Question 5

What are the causes of upper GI bleeding?

Answer 5

Ulcers
Inflammation
Malignancy
Varices
Angiodysplasia
Mallory-Weiss tear (tear at oesophago-gastric junction after period of retching/vomiting)

Question 6

What are the risk factors for peptic ulcers?

Answer 6

H. pylori
NSAIDs/Aspirin
Alcohol excess
Systemic illness = stress ulcers

Question 7

What are the investigations for upper GI bleeding?

Answer 7

Upper GI endoscopy

Question 8

What are the causes of lower GI bleeding?

Answer 8

Haemorrhoids
Diverticular disease
Angiodysplasia
Carcinoma/polyps
Ischaemic colitis
Radiation enteropathy/proctitis
IBD

Question 9

What is the treatment for haemorrhoids?

Answer 9

Elective surgical intervention

Question 10

What is the treatment for angiodysplasia?

Answer 10

Argon phototherapy

Medication (tranexamic acid, thalidomide)

Question 11

What are the complications of ischaemic colitis?

Answer 11

Gangrene

Perforation

Question 12

What is the treatment for radiation proctitis?

Answer 12

APC
Sulcrafate enemas
Hyperbaric oxygen

Question 13

What are the investigations for lower GI bleeding?

Answer 13

Flexible sigmoidoscopy
Colonoscopy
CT angiography

Question 14

What are the small bowel causes of lower GI bleeding?

Answer 14

Meckel's diverticulum
SB angiodysplasia
SB tumour/GIST
SB ulceration (NSAIDs)
Aortoentero fistulation (after AAA repair)

Question 15

What are the small bowel investigations?

Answer 15

CT angiogram
Meckel’s scan
Capsule endoscopy
Double balloon enteroscopy

Question 16

What is the management of GI bleeding?

Answer 16

Endoscopy once stable
Withhold/reverse contributory medication
Blood products
CT angiography/radiology/surgical interventions if required

Question 17

What are the signs of haemorrhagic shock?

Answer 17

High RR
Rapid pulse
Anxiety/confusion
Cool clammy skin
Low urine output
Low BP

Question 18

What is the Rockall score used for?

Answer 18

Primarily to predict death but can also be used to predict re-bleeding

Question 19

How are peptic ulcers managed?

Answer 19

Proton pump inhibitors
Endoscopy with endotherapy
Angiography with embolisation
Laparotomy

Question 20

What are the endoscopic therapy options for peptic ulcers?

Answer 20

Injection = adrenaline
Thermal - contact
Mechanical - clip
Haemospray
Combination therapy (most effective) = adrenaline + thermal/clips

Question 21

How are varices managed?

Answer 21

Endotherapy
Oesophageal - band ligation, glue injection
Gastric - glue injection
Rectal - glue injection
(Ideally intubated for airway protection)
IV terlipressin (vasoconstrictor)
IV broad spectrum antibiotics 
Correct coagulopathy