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
Outline the Rockall score criteria
What type of bacteria is H. pylori?
Gram -ve aerophillic helicobacter
Outline the pathophysiology of Oesophageal varices
- Portal HTN
- Splanchnic vasodilation
- Increased cardiac output and portal flow
- Portal-systemic collaterals
