Acute upper gastrointestinal bleeding Flashcards
What are the GI red flag symptoms?
- Unintentional/unexplained weight loss
- Recurrent vomiting
- Dysphagia
- Evidence of GI bleeding
- Abdominal masses
- Rectal masses
- FHx of bowel cancer
- Altered bowl habits (for 6+wk in over 60s)
What are the cardinal features of an acute upper GI bleed?
- Haematemesis
- Melaena (black tarry stools)
- Coffee-ground vomit
What does the passage of dark blood and clots per rectum indicate?
Lower GI bleeding
Name five causes of Upper GI bleeding
- Peptic ulcer disease (50%)
- Mallory-Weiss syndrome (5-10%)
- Oesophageal varices (10-20%)
- Gastritis/gastric erosions (15-20%)
- NSAIDs, aspirin, steroids, thrombolytics, anticoagulants
- Reflux oesophagitis (2-5%)
- Gastric carcinoma
- Bleeding disorders
- Aorto-enteric fistula
- Angiodysplasia
- Meckel’s diverticulum
What is Mallory-Weiss syndrome?
Bleeding secondary to a longitudinal mucosal lacerations of the oesophagus.
Outline the risk assessment of an acute upper GI bleed
- Blatchford score at first assessment
- Rockall score after endoscopy
What percentage of acute Upper GI bleeds resolve spontaneously?
85%
What is the Blatchford score?
A risk assessment tool used to determine the need for interventions such as transfusion or endoscopy
What markers are used to generate a Blatchford score?
- Urea
- Hb
- Systolic BP
- Other clinical markers
- HR
- Melaena
- Syncope
- Hepatic disease
- Cardiac failure
If the patient has a Blatchford score of 0, how does this affect management?
Consider early discharge for patients with a pre-endoscopy Blatchford score of 0
What does a Blatchford score of 6+ indicate?
>50% risk of need for intervention ➔ Admission
Outline the initial management of an acute upper GI bleed
- Urgent investigations:
- FBC; U+Es; clotting
- G+S; X-match six units
- Resuscitation if hypovolaemic
- Large bore IV cannula in each arm
- Blood within 2h; consider collids
- Consider activating major haemorrhage protocol
- Referral to GI team for emergency endoscopy
Name two indications for blood transfusion
- Haemodynamic instability
- Haemoglobin <100g/L in recent or active bleeding
What is the timing of endoscopy in acute upper GI bleed?
- Unstable with severe acute upper GI bleed
- Immediately after resuscitation
- All other upper GI bleed
- Within 24hr of admission
What endoscopic management is available for non-variceal upper GI bleeding?
One of the following:
- Mechanical clips ± adrenaline
- Thermal coagulation + adrenaline
- Fibrin/thrombin + adrenaline
What endoscopic management is available for variceal upper GI bleeding?
Following resuscitation:
- Antibiotic prophylaxis: Co-amoxiclav or Ciprofloxacin for 72h
- IV terlipressin for 72h
At endoscopy:
- Band ligation (oesophageal) or Butyl acrylate injection (gastric)
- Sengstaken-Blakemore tube: balloon tamponade
- TIPSS
Why is an antral biopsy taken during endoscopy in upper GI bleeding?
To look for H. pylori
What medication should be prescribed after endoscopic management of Upper GI bleeding?
- Continue low-dose aspirin for secondary prevention
- Non-variceal: Omeprazole (PPI)
- Variceal: lactulose prophylaxis for hepatic encephalopathy
What is the Rockall score?
A tool to help predict the risk of rebleeding and mortality after acute upper GI bleeding.
Outline the Rockall score criteria
What Rockall score is an indication for surgery?
Initial Rockall score >6
What is the commonest cause of peptic ulcer disease?
H. pylori infection
(95% of duodenal ulcers, 80% of gastric ulcers)
Name three drugs associated with peptic ulcer disease
- NSAIDs
- Steroids
- Bisphosphonates
What type of bacteria is H. pylori?
Gram -ve aerophillic helicobacter
How can H. pylori infection be detected?
- Urease breath test
- Antral biopsy + histology
Outline treatment of H. pylori
Triple therapy BD for 7 days
- Omeprazole or Lansoprazole
- Clarithromycin 500mg
- Amoxicillin 1g
Pen allergic: PPI + Clarithromycin 250mg + Metronidazole 400mg
Name two causes of Mallory-Weiss syndrome
- Alcoholic dry heaving and vomiting
- Bulimia nervosa
Outline the pathophysiology of Oesophageal varices
- Portal HTN
- Splanchnic vasodilation
- Increased cardiac output and portal flow
- Portal-systemic collaterals
Name three causes of portal HTN
- Pre-hepatic:
- Thrombosis
- Intra-hepatic:
- Cirrhosis: commonest cause in UK
- Schistosomiasis: commonest cause worldwide
- Sarcoidosis
- Post-hepatic:
- Budd-Chiara syndrome
- Right HF
- Constrictive pericarditis
