Upper GI Bleeding Causes and History

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Questions and Answers

What is a primary objective of surgery in managing re-bleeding?

To completely eliminate all symptoms

To achieve curative goals and reduce acid component (correct)

To avoid the use of medication

To perform a diagnostic procedure

Which scoring systems are used for risk stratification?

Rockwell Score and Glasgow Score

Rockall Score and CURB-65

Rockall Score and APACHE II Score

Rockall Score and Blatchford Scoring System (correct)

Which of the following is NOT a risk factor to consider during risk stratification?

Type of previous surgeries (correct)

Shock due to tachycardia

Major co-morbid conditions

Age of the patient

What is the initial treatment for H. Pylori infection?

PPI combined with Clarithromycin and Amoxicillin or Metronidazole Signup and view all the answers

What is a possible complication when using CT for mesenteric angiography?

Risk of nephropathy due to contrast usage Signup and view all the answers

If initial endoscopic hemostasis fails, what is the next recommended intervention?

CT mesenteric angiography or embolization Signup and view all the answers

What is the recommended duration for administering a PPI after treating H. Pylori infection?

6 weeks Signup and view all the answers

Which of the following is an indication of stigmata of recent hemorrhage during physical examination?

Tachycardia or hypotension Signup and view all the answers

What is a Curling ulcer?

A large acute ulcer in the duodenum resulting from burns Signup and view all the answers

Which of the following is associated with a Mallory-Weiss tear?

Longitudinal tear below the gastroesophageal junction Signup and view all the answers

What type of bleeding is most commonly associated with a Cushing’s ulcer?

Non-variceal bleed Signup and view all the answers

Dieulafoy’s disease is characterized by which feature?

Bleeding from the gastric fundus due to an AVM Signup and view all the answers

What are some signs of anemia that can be observed?

Tachycardia, conjunctival pallor, and a short systolic murmur Signup and view all the answers

Which condition can lead to anemia signs such as pallor of the palmar creases?

Severe blood loss from a Mallory-Weiss tear Signup and view all the answers

In which patient demographic is Dieulafoy’s disease more commonly found?

More common in males with multiple co-morbidities Signup and view all the answers

What is the primary cause of a Cushing's ulcer?

Elevated intracranial pressure Signup and view all the answers

What is the primary purpose of conducting a CT scan in the context of staging cancer?

To exclude the presence of metastatic disease Signup and view all the answers

Which imaging technique combines the spatial resolution of CT with the contrast resolution of PET?

Positron Emission Tomography (PET) Signup and view all the answers

In patients believed to have local-regional disease, what percentage of cases does routine laparoscopy detect small volume peritoneal and liver metastases?

20-30% Signup and view all the answers

Which stage indicates a Tis classification in cancer staging?

Stage 0 Signup and view all the answers

What laboratory marker is considered poor nutritional status when its level falls below 35?

Albumin Signup and view all the answers

Which staging classification reflects the presence of both nodal involvement and distant metastasis?

Stage 4a Signup and view all the answers

Which of the following tests is primarily used to assess hemoglobin levels?

Full Blood Count (FBC) Signup and view all the answers

What limitation does a CT scan have regarding nodal involvement assessment?

It has limited accuracy in determining nodal involvement. Signup and view all the answers

What symptoms are associated with intermediate stage gastric carcinoma?

Anemia and melena Signup and view all the answers

Which of the following complications are indicative of symptomatic anemia?

Chest pain and lethargy Signup and view all the answers

In the management of a patient with massive hematemesis, what is the recommended initial fluid resuscitation?

1L N/S quickly (over 15 minutes) Signup and view all the answers

What is a potential consequence of fluid overload during resuscitation?

Pulmonary edema Signup and view all the answers

Which class of blood loss is characterized by a narrowed pulse pressure and resting tachycardia?

Class 1 (15-30%) Signup and view all the answers

What should be suspected in a patient with bleeding and no history of alcohol abuse or NSAID use?

Upper gastrointestinal malignancy Signup and view all the answers

What condition predisposes older patients (>60) to hypoxemia?

Chronic obstructive pulmonary disease (COPD) Signup and view all the answers

In which stage of gastric carcinoma is a patient likely to experience loss of appetite and obstructive jaundice?

Late stage Signup and view all the answers

What is the primary symptom of haemoptysis?

Bloody expectoration from the larynx, trachea, bronchi, and lungs Signup and view all the answers

How does melena differ from iron stool when mixed with water?

Melena dissolves completely, whereas iron stool sedimentates. Signup and view all the answers

What characteristic of the vomitus indicates hematemesis?

Vomit is brown and has a coffee-ground appearance. Signup and view all the answers

What crucial detail should be assessed in a patient with a history of variceal bleeding?

Whether the patient has regular screening and banding. Signup and view all the answers

A brisk upper GI bleed can cause what type of bleeding?

Frank PR bleeding Signup and view all the answers

What factor is least likely to influence the color of vomited blood in hematemesis?

The patient's hydration status Signup and view all the answers

What is the expected appearance of expectorated blood in a case of haemoptysis?

Frothy and bright red Signup and view all the answers

Which sign would suggest that the vomited blood has been altered by gastric acid?

Coffee-ground appearance Signup and view all the answers

What is a common site for lymphatic spread from gastric cancer?

Left supraclavicular nodes Signup and view all the answers

Which type of gastric cancer accounts for the largest percentage of cases?

Adenocarcinoma Signup and view all the answers

What mechanism is primarily associated with the spread of gastric neuroendocrine tumors?

Local lymphatic spread to peri-gastric lymph nodes Signup and view all the answers

Which of the following is NOT a potential site of haematogenous spread in gastric cancer?

Transverse colon Signup and view all the answers

Which histological type is categorized as a non-adenocarcinoma type of gastric cancer?

Gastric Lymphoma Signup and view all the answers

What is a defining feature of gastrointestinal stromal tumours (GISTs)?

c-KIT gain of function mutation Signup and view all the answers

Which artery's branches are implicated in the lymphatic spread of gastric cancer?

Left gastric artery Signup and view all the answers

What condition is associated with hypergastrinemia in gastric cancer development?

H. Pylori chronic gastritis Signup and view all the answers

Study Notes

Upper Gastrointestinal Bleeding (UGIT) Causes

Variceal Bleed: Gastro-oesophageal varices (30%) are a common cause of upper GI bleeding.
Non-variceal Bleed:
- Mallory-Weiss tear (10%)
- Peptic ulcer disease (bleeding peptic ulcer) (50%)
- Gastritis, gastric erosions, duodenitis
- Gastric malignancy (10%)
- Dieulafoy lesion - large tortuous arteriole in the stomach
- Aorto-enteric fistula (5%)
- Bleeding from other sources: Haemoptysis, nasopharyngeal bleeding

History (Stable Patient)

Nature of bleeding:
- Confirm hematemesis (vomiting blood) or rule out haemoptysis (coughing up blood).
- Haemoptysis: Bloody expectoration from the lungs.
- Hematemesis (blood or coffee-ground emesis): Vomiting of blood. Vomit colour depends on stomach acid contact time (fresh red = severe, coffee grounds = less severe).
- Melena (black tarry stool): Passage of altered blood from the upper GI tract (proximal to Treitz ligament).
- Fresh versus Stale Melena: Fresh melena is jet black and tarry, often almost liquid-like; stale melena is black-grey and dull, and sometimes mixed with normal stool.

Factors predictive of UBGIT

Patient-reported history of melena (LR: 5.1-5.9)
Melenic stool on examination (LR: 25)
Blood or coffee grounds detected during NG lavage (LR: 9.6)
Ratio of BUN (Blood Urea Nitrogen) to Serum Cr > 30 (LR: 7.5).

Determining Etiology (variceal vs. non-variceal bleed)

Previous variceal bleed: ask about banding or OGD (upper endoscopy) screening.
Chronic liver disease: identify potential risk factors (alcohol, hepatitis B/C).

Physical Examination

Vital Signs: Assess hemodynamic stability and postural blood pressure. Include any tachycardia.
Determine Etiology: Check for stigmata of chronic liver disease (i.e. jaundice).
Look for complications: Signs of anemia (pallor of skin or mucous membranes). Cardiac auscultation, pulse (e.g. rate, strength), and condition of hands. Lung and abdominal examination to exclude peritonism.

Immediate Management

Resuscitation:
- Airway assessment and management.
- IV access with large-bore cannulae.
- Bloods for investigation: Full blood count (FBC), Urea and electrolytes (U&E), coagulation profile (PT/PTT), Liver function tests (LFT), arterial blood gases (ABGs), lactate levels, ECG, chest x-ray (CXR).
- Initial IV fluid resuscitation: normal saline (0.9% NaCl).
- Closely monitor patient response.
Adjuncts:
- Blood transfusion strategy (maintain Hb > 7g/dL).
- Platelets if patient on antiplatelets.
- Fresh frozen plasma (FFP) if patient is on anticoagulants or PT/PTT is prolonged.
- NG tube if hematemesis present to prevent aspiration.
Early medications: IV omeprazole to increase stomach pH and stabilize blood clots. If varices suspected, consider somatostatin/ocreotide, and broad-spectrum antibiotics.
Monitoring: Shock (HR, BP) and urine output, and patient parameters hourly. Stop NSAIDs, antiplatelets and anticoagulants if any.

Diagnostic Studies

Acute GI bleed: OGD, blood/bile/no blood, Tagged RBC Scan/Angiography
OGD to localize and treat.

Subsequent Management

Risk Stratification: Assess using Rockall score or Blatchford scoring system. Include age and shock status prior to and after OGD.
Management of re-bleeding: Repeat OGD for haemostasis. Consider surgery if endoscopic procedure fails.

Variceal Bleeding

Active Variceal Bleed:
- Resuscitate, IV access, airway management.
- Labs (GXM, FBC, U&E, PT/PTT, LFT, ABG, etc.).
- Fluids, blood transfusion if Hb < 7g/dL aiming for > 7g/dL
- IV somatostatin/ocreotide, IV antibiotics, Omeprazole.
Prophylaxis (Prevention):
- Band ligation and beta-blockers to reduce bleeding risk. This includes long-acting nitrates if beta-blockers contraindicated.

Gastric Cancer

Epidemiology: 7th/8th most common cancers in males/females. Ethnicity, gender, and genetics are factors.
Risk Factors: H. pylori infection. Diet (processed foods, smoked, high salt). Smoking, Family history, Alcohol, GERD, previous gastric surgery, etc.
Classification: Borrmann's classification (polypoid, excavating, ulcerative, diffuse thickening).
Histological types: Adenocarcinomas (95%) (intestinal/diffuse). Non-adenocarcinomas (5%): (neuroendocrine, lymphoma, GIST).

Investigations

OGD and biopsies
Barium meal and follow through

Pathophysiology:

Active Processes: Gastric acid secretion, pepsin production, inflammation, presence of H. pylori, and prolonged NSAID use.
Protective Mechanisms: Mucus, bicarbonate secretion, blood flow and cell regeneration.

Treatment (complicated PUD):

Haemorrhage: Endoscopy [epinephrine injection, thermal, mechanical], pharmacologic (omeprazole), TAE (transcatheter arterial embolization) if needed, surgery.
Perforation: NBM. IV hydration, antibiotics, NGT with low suction, serial abdominal exam.
Gastric outlet obstruction: NGT. IV antisecretory agents (e.g., omeprazole), possible endoscopic or surgical interventions (dilation).
Massive transfusion complications: Fluid overload, immunological complications, infections, and metabolic disturbance.

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Description

Test your knowledge on the causes of upper gastrointestinal bleeding (UGIT) and understand the distinctions between hematemesis and hemoptysis. This quiz covers various topics including non-variceal and variceal bleeds, as well as important historical considerations for stable patients. Get ready to deepen your understanding of UGIT!