68. Hematemesis /Upper GI bleed

Question 1

ddx upper GI bleeding:

Answer 1

Oesophageal varices :may have ascites, jaundice

Mallory-Weiss tear, which is a tear of the oesophageal mucous membrane

Ulcers of the stomach or duodenum :may have dyspepsia, epigastric pain

Oesophagitis

Cancers of the stomach or duodenum

Question 2

Presenting complaints upper GI bleeding

Answer 2

Haematemesis
Coffee ground vomit
Melena (tar like stool (digested blood))
Haemodynamic instability (low bp, tachycardia, signs of shock)

Question 3

initial management ?upper GI bleed

Answer 3

A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 large bore cannula)
T – Transfuse
E – Endoscopy (arrange urgent endoscopy within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs) (if ?varices give terlipressin and broad spec abx iv)

Question 4

assessment tool ?upper GI bleed

Answer 4

Glasgow-blatchford score
Drop in Hb
Rise in urea
Blood pressure
Heart rate
Melaena
Syncopy
Score >0 means high risk

Question 5

Plan invetsigation and management ?upper GI bleed

Answer 5

Invetigation
1. Bloods
Haemoglobin (FBC)
Urea (U&Es)
Coagulation (INR, FBC for platelets)
Liver disease (LFTs)
Crossmatch 2 units of blood
2. Endoscopy with treatment

Management
1. stabilise ie transfusion
2. Endoscopy with banding (varices), cauterization (bleeding vessel)
3. If oesophageal varices: prophylactic broad spectrum abx and Terlipressin

Question 6

HoPC upper gi bleed oesophageal varices

Answer 6

Usually a large volume of fresh blood. Swallowed blood may cause melena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.

Question 7

HoPC upper GI bleed oesophagitis

Answer 7

Small volume of fresh blood, often streaking vomit. Malena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms.

Question 8

what blood test result indicates upper GI bleed is more likely than lower GI bleed

Answer 8

High urea levels can indicate an upper GI bleed versus lower GI bleed

Question 9

priamry prophylaxis of varices bleeidng

Answer 9

ligation
non-selective beta blockers

1) by blocking β1 receptors and reducing cardiac output, and 2) by blocking β2 receptors, producing splanchnic vasoconstriction and reducing portal flow.

Question 10

what score is used after endoscopy upper gi bleed?

Answer 10

rockall score