[32] Upper GI Bleeding Flashcards
What is it important to know in the history in a patient with a upper GI bleed?
Previous bleeds Dyspepsia or known ulcers Liver disease, or oesophageal varices Dysphagia or weight loss Drugs and alcohol Co-morbidities
What may be found on examination in upper GI bleeding?
Signs of CLD
Signs of shock
What signs of shock might be seen on examination in upper GI bleeding?
Cool and clammy CRT >2s Decreased BP or postural hypotension Decreased urine output Tachycardia Decreased GCS
What might be found on PR in upper GI bleeding?
Melaena
What are the common causes of upper GI bleeding, in order
PUD Acute erosions/gastritis Mallory-Weiss tear Varices Oesophagitis Cancer of stomach or oesophagus
What kind of PUD more commonly causes upper GI bleeding?
DU
What is the purpose of a Rockall score?
Prediction of re-bleeding and mortality
What % of re-bleeders die in upper GI bleeds?
40%
What are the components to the Rockall score?
Initial
Final
When is the initial Rockall score calculated?
Before endoscopy
When is the final Rockall score calculated?
After endoscopy
What is taken into account in the initial Rockall score?
Age
Shock - BP and pulse
Co-morbidities
What is taken into account in the final Rockall score?
Final diagnosis, and evidence of recent haemorrhage
What evidence for recent haemorrhage might be seen on endoscopy?
Active bleeding
Visible vessel
Adherent clot
How can the Rockall score be used to guide surgery?
Initial score of 3 or more, or final score of 6 or more are indications for surgery
What is the pathophysiology of oesophageal varices?
Portal hypertension leads to dilated veins at the sites of porto-systemic anastomosis
What veins are affected in oesophageal varices?
Left gastric
Inferior oesophageal
What % of those with portal hypertension with bleed from varices?
30-50%
What is the overall mortality of oesophageal varices?
25%
What is the mortality from oesophageal varices dependant on?
The severity of liver disease
What are the categories of causes of portal hypertension?
Pre-hepatic
Hepatic
Post-hepatic
What are the pre-hepatic causes of portal hypertension?
Portal vein thrombosis
What are the hepatic causes of portal hypertension?
Cirrhosis
Schistosomiasis
Sarcoidosis
What % of cases of portal hypertension are due to cirrhosis in the UK?
80%
What are the post-hepatic causes of portal hypertension?
Budd-Chiari
RHF
Constrictive pericarditis
What is first line in preventing bleeding from oesophageal varices?
Beta-blockers
Endoscopic banding
What is second line in preventing bleeding from oesophageal varices?
Beta-blockers
Endoscopic banding
TIPSS (transjugular intrahepatic porto-sytemic shunt)
What happens in TIPSS?
Interventional radiology create an artificial channel between the hepatic vein and portal vein, causing a decrease in portal pressure
How is an artificial channel between the hepatic vein and portal vein created in TIPSS?
Colapinto needle creates a tract through the liver parenchyma, which is expanded using a balloon and maintained by placement of a stent
What is the role of TIPSS in oesophageal varices?
It can be used prophylactically, or acutely if endoscopic therapy fails to control variceal bleeding
What are the steps in the management of upper GI bleeding?
- Resuscitate
- Blood if remains shocked
- Maintenance
- Urgent endoscopy
- Medications and monitoring
What is involved in resuscitation in upper GI bleeding?
Keep head down
100% oxygen, protect airway
2x14G cannula, and IV crystalloid infusion up to 1L
Take bloods
What bloods need to be taken during the resuscitate stage of upper GI bleeding?
FBC U&E LFTs Clotting Cross match 6 units ABG Glucose
What additional step should be taken after resuscitate and giving blood in variceal bleeding?
Terlipressin IV
Prophylactic antibiotics
What is terlipressin?
A splanchnic vasopressor
What prophylactic antibiotic might be given in variceal bleeds?
Ciprofloxacin 1g/24hours
What is involved in maintenance management in upper GI bleeding?
Crystalloid IVI, with blood transfusion if necessary Catheter Consider CVP Correct coagulopathy Thiamine if alcoholic Notify surgeons of severe bleeds
What Hb should be aimed for in the maintenance stage of upper GI bleeding management?
100 or above
What CVP should be aimed for in the maintenance stage of upper GI bleeding management?
> 5cm H2O
How can coagulopathy be corrected in upper GI bleeding management?
Vitamin K
FFP
Platelets
What are the options for achieving haemostasis of a vessel or ulcer in upper GI bleeding?
Adrenaline injection
Thermal/laser coagulation
Fibrin glue
Endoclips
What are the options for stopping variceal bleeding
2 of banding, sclerotherapy, adrenaline, and coagulation
Balloon tamponade
TIPSS
What equipment is used for balloon tamponade in variceal bleeding?
Sengstaken-Blakemore tube
When is balloon tamponade used in variceal bleeding?
Only when exsanguinating haemorrhage or failure of endoscopic therapy
When is TIPSS used in variceal bleeding?
Only if bleeding can’t be stopped endoscopically
What management is required for upper GI bleeding after endoscopy?
Omeprazole IV and continuation of PO Keep NBM for 24 hours Daily bloods H. Pylori testing and eradication Stop NSAIDs, steroids etc
Why should omeprazole IV be given in upper GI bleeding?
Reduces the risk of rebleeding
What should happen after patients with upper GI bleeding have been kept NBM for 24 hours?
Transition to clear fluids, then light diet at 48 hours
What daily bloods need to be done after upper GI bleeding?
FBC
U&E
LFT
Clotting
What are the indications for surgery in upper GI bleeding?
Re-bleeding
Bleeding despite transfusing 6u
Uncontrollable bleeding at endoscopy
Initial Rockall score >3, or final >6
How is surgery for upper GI bleeding performed?
Open stomach, find bleeder, and underrun vessel
Why should normal saline be avoided in uncompensated liver disease?
It worsens ascites
What should be used instead of saline in uncompensated liver disease?
Blood or albumin for resus, and 5% dex for maintenance
