Acute Upper GI bleed

Question 1

Definition

Answer 1

GI blood loss whose origin is proximal to the ligament of Treitz at the duodenojejunal junction.

Question 2

Causes?

Answer 2

-Peptic ulceration
-Mucosal inflammation (oesophagitis, gastritis, duodenitis)
-Oesophageal varices
-Mallory-Weiss tear
-Gastric carcinoma
-Drugs (NSAIDs, Aspirin, Steroids, Thrombolytics, Anticoagulants)
Rare:
-Coagulation disorders (thrombocytopenia, warfarin)
-Aortic-enteric fistula (esp. after aortic surgey)
-Benign tumours (leiomyomas, carcinoid tumours, angiomas)
-Congenital (Ehler’s-Danlos, Osler-Weber-Rendu, pseudoxanthoma elasticum)
-Portal hypertensive gastropathy

Question 3

Risk factors?

Answer 3

Age
Cancer & Heart failure
Liver disease
Continued bleeding
Elevated urea
Passage of PR blood

Question 4

Clinical presentation

Answer 4

Pain – often not in the elderly.
Hematemesis and/or malaena
Major upper GI bleeds may have fresh PR bleeding.
Associated symptoms: ab pain, weight loss, anorexia. Syncope suggests significant bleed.
Dx: NSAIDs, aspirin, warfarin, iron. –OH consumption.

Question 5

Signs?

Answer 5

Check ABCDE.
Assess for hypovolaemic shock (peripherally shut down, cap refill >2secs, urine output <1/2mL/kg/h, GCS/signs of encephalopathy, tachycardia >100bpm, systolic BP <100mmHg)
Look for any available vomit or faeces.
Check for aortic masses, tenderness or surgical scars.
Look for stigmata of liver disease.
Check for faecal occult blood (FOB)

Question 6

Differentials

Answer 6

PUD
Oesophageal varices
Oesophagitis
Mallory- Weiss tear
Gastric varices
Arteriovenous malformation
GI tumour
Coagulopathy

Question 7

Investigations

Answer 7

FBC, clotting screen, U&E, blood glucose, group and save or cross-matching.
Expect: urea to be high but creatine normal unless renal dysfunction.
Check SpO2 (obtain ABG if <94%) and consider CXR and ECG or endoscopy to find source of bleeding.
Rockall Scoring System

Question 8

Management

Answer 8

ABCDE.

1. Maintain SpO2 94-98%. Insert 2 large bore cannulae, send FBC, U&E, LFTs & clotting, cross-match.
2. Start IV fluids followed by blood if necessary.
3. Avoid omeprazole unless patient has known peptic ulcer
4. Organise urgent endoscopy, CXR, ECG & ABG, consider CVP line
5. Monitor pulse, BP, CVP hourly until stable
6. If anticoagulated, discuss with haematologist and give Vit K/clotting factors/FFP/platelets accordingly.
7. Insert urinary catheter and monitor urinary output
8. If patients have severe uncontrolled variceal bleeding, severe encephalopathy, hypoxia, acute agitation or evidence of aspiration have their airways secured by tracheal intubation if necessary.

Question 9

Complications

Answer 9

Mortality, Fe deficiency anaemia

Question 10

What is the Rockall Scoring system?

Answer 10

Variables: Age, shock, co-morbidities, signs of bleeding, endoscopic diagnosis
Score from 0-3 in each section
Any score >0 signifies increased risk of mortality.
If score = 0 then can consider discharge. If >0 request urgent endoscopy.

Question 11

If due to oesophageal varices or signs of hepatic failure?..

Answer 11

• Arrange urgent endoscopy
• Commence fluid resus
• Give terlipressin (2mg IV every 4-6hrs)
• Check INR and give IV Vit K if prolonged
• Give prophylactic ATX e.g. ciprofloxacin or 2nd/3rd generation cephalosporin which may decrease mortality in severe haemorrhage
• Consider gastric balloon
  Surgery: Variceal banding, balloon tamponade