3) Upper GI Bleeds Flashcards
Common causes of GI Bleeds?
- Peptic Ulcer (duodenal>gastric)
- Gastric Erosions/Gastritis
- Mallory-Weiss Tear
- Oesophageal Varices (5% bleeds, 80% mortality)
- Duodenitis
- Oesophagits
- Tumours
- Dieulafoy Lesions
- HHT
- Aortoenteric fistula
- Clotting Defects
How should patients with GI Bleed be risk assessed?
-Blatchford score at first assessment
-Full Rockall Score after endoscopy
Consider early discharge for pts with pre-endoscopy Blatchford score of 0
S+S of GI Bleed?
- Haemtemesis or Melaena
- Dizziness
- Abdo Pain
- Hypotension
- Postural Hypotension
- Tachycardia
- Dec. JVP
- Dec. Urine Output
- Signs of chronic liver disease
Initial Management of GI Bleed?
Is the Patient Shocked? Yes: See separate Card No: 2 Wide bore cannulae, start saline and monitor vital signs -Aim to keep Hb >8 -Check Bloods
How should a shocked patient initially be managed?
- Protect airway and NBM
- two Cannula
- All bloods, cross match 6 units
- High flow 02
- Rapid fluid infusion
- if remains shocked, give blood?
- Correct clotting abnormalities
- Set up CVP line
- Catheterise
- Monitor
How should patients be transfused according to NICE?
- Transfuse patients with massive bleeding with blood, platelets and clotting factors in line with local protocols for managing massive bleeding.
- Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion.
- Do not offer platelet transfusion to patients who are not actively bleeding and are haemodynamically stable.
- Offer platelet transfusion to patients who are actively bleeding and have a platelet count of less than 50 x 109/litre.
- Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
When should endoscopy take place?
- Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation.
- Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding.
What endoscopic treatment can be used in non variceal bleeding?
a mechanical method (for example, clips) with or without adrenaline
thermal coagulation with adrenaline
fibrin or thrombin with adrenaline.
DO not use adrenaline as monotherapy
When should PPIs be offered to patients with non variceal bleeding?
If stigmata of recent hemorrhage shown on endoscopy- not before
How should Variceal (of any type) Bleeding be Managed?
- Offer terlipressin to patients with suspected variceal bleeding at presentation. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use
- Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.eg cipro 1g/24hr
How should oesophageal variceal bleeding be definitively managed?
- Band Ligation
- Consider TIPS if bleeding is not controlled by band ligation
- Balloon tamponade can be used if failure of band
How should gastric varices be treated?
- Offer endoscopic injection of N-butyl-2-cyanoacrylate
- Offer TIPS if bleeding not controlled by injection
How should patients on NSAIDs, Asprin or clopidogrel be managed?
- Continue low dose aspirin for secondary prevention of vascular events if haemostasis achieved
- Stop other NSAIDS during the acute phase
- Discuss clopidogrel with pt and specialist
What happens to Urea in GI BLeed?
Goes up
What care is needed after endoscopy?
- Omeprazole can prevent rebleeds
- NBM 24hr then progress to clear fluid and light diet
- Test for HPylori if ulcer
What are indications for surgery?
- Rebleeding
- Bleeding despite transfusing 6u
- Uncontrollable bleeding at endoscopy
- INitial rockall score >3 or total >6
What maintenance therapy is needed after resus in GI Bleed?
Crystalloid IVI, transfuse if necessary (keep Hb≥10)
Catheter + consider CVP (aim for >5cm H2O)
Correct coagulopathy: vit K, FFP, platelets
Thiamine if EtOH
Notify surgeons of severe bleeds
What are the important things to ask in Hx in GI Bleed?
- Previous Bleeds
- Dyspepsia or known ulcer
- Liver disease, Known Varices
- Alcohol
- Comorbidities
- Dysphagia/ wt. loss
What may you find O/E in GI Bleed?
- Signs of chronic Liver disease
- Melaena on PR
- Signs of Shock (low BP, HIgh HR, Low urine, Cap refil slow, Dec. GCS, Post drop)
What are the common Causes of GI Bleed?
Common to Rare:
- Peptic Ulcer Disease (DU common)
- Gastritis/erosions
- Mallory Weiss Tear
- Varices
- Oesophagitis
- Gastric CA/Oesophageal CA
What is a Rockall Score?
Prediction of bleeding and mortality- 40% of rebleeders die
What is in the initial Rockall Score?
-Age
-Shock
-Comorbidities
>3 indication for surgery
What is the post endoscopic ROckall Score?
-Final Diagnosis
-Evidence of recent haemorrhage
(out of 11 now)
>6 indicates surgery
What are oesophageal Varices?
Portal HTN leads to dilated veins at points of porto-systemic anastamosis- L. Gastric and inferior Oesophageal Veins
-30-50% with portal HTN will bleed from varices
what mortality is associated with variceal bleeds?
25%- increasing w/ severity of Liver disease
Causes of portal HTN?
Pre Hepatic: Portal Vein Thrombosis
Hepatic: Cirrhosis (80% UK), Schisto (common worldwide), Sarcoidosis
Post Hepatic: Budd Chiari, RHF
How can bleeds be prevented?
1o- Repeat endoscpoic banding, B-Blockers
-2o- Ditto and TIPS
What is TIPSS?
-artificial channel between hepatic vein and
portal vein → ↓ portal pressure.
-Colapinto needle creates tract through liver
parenchyma which is expand using a balloon and
maintained by placement of a stent.
-Used prophylactically or acutely if endoscopic therapy
fails to control variceal bleeding.
What is a blatchford Score?
-screening tool to assess the likelihood that a patient with an acute upper gastrointestinal bleeding (UGIB) will need to have medical intervention such as a blood transfusion or endoscopic intervention
What is involved in blatchford score?
Score is 0 if:
Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)
Systolic blood pressure >109 mm Hg
Pulse <100/minute
Blood urea nitrogen level <6.5 mg/dL
No melena or syncope
No past or present liver disease or heart failure
How would decompensated liver disease alter your management?
Avoid 0.9% NS in uncompensated liver disease (worsens
ascites). Use blood or albumin for resus and 5% dex for
maintenance
