acute UPPER GI BLEEDING / haemetesis Flashcards
etiology of upper GI bleeding ?
Peptic ulcer disease (PUD) 35–50%. - common posterior duodenal ulcer
- Gastroduodenal erosions 8–15%.
- Oesophagitis 5–15%. / gastritis / duodenitis
- Mallory–Weiss tear 15%. after severe vomiting
- Varices 5–10%. - esophageal or gastric
upper gi cancer
clinical manifestation of upper GI bleed?
Haematemesis: typically coffee-ground like in appearance due to the presence of partially digested blood.
its red if active
dark smelling tarry stools = melena - active
fresh rectal bleeding., can occur in the context of profuse upper gastrointestinal haemorrhage due to rapid transit of blood
(iron therapy can cause black stool - but less foul smelling)
Abdominal pain: typically epigastric in location, but can be diffuse.
Pre-syncope/syncope: due to hypovolaemia and secondary cerebral hypoperfusion.
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clinical signs
Tachycardia
Hypotension
Abdominal tenderness
diagnose GI bleeding
stool samples - melena
PR
esophagogastroduodenoscopy - if thats negative then colonoscopy
===== CBC - hb , platlet cogulation pannel liver chemistry urea high due to GI absobrtio and metabolism of blood
what is the management to upper GI bleeding?
cirrhosis - increase in uncongugated bilirubin , decrease in albumin ,
INTGRODUCE YOURSELF
A
B -
C
cross match 6 units of blood for patients blood group and request blood product
fbc lft - cirrhosis cogulation screen cep clotting pannel
c -
evel of consciousness using the AVPU scale:
GCS
pupils
Blood glucose and ketones
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E
expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat.
Inspect the patient for stigmata of chronic liver disease and/or coagulopathy:
Bruising Petechiae (e.g. thrombocytopenia) Spider naevi Caput medusae Ascites
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FLUID RESUS
500ml bolus of hartmanns solution or 0.9 percent sodium chloride over 15 mins
After each fluid bolus, reassess for clinical evidence of fluid overload
Repeat administration of fluid boluses up to four times up to 2L
blood transfusion needs to be arranged hb< 7g/dl and if there is still signs of of impaired oxygen support - pale , sob
Blood transfusion should be guided by haemoglobin levels and the estimated volume of blood lost.
check platelets - which can be given ( platelets administered if below 50x10^3 / ul )
fresh frozen plasma and
cyroprecipitate
if fibrinogen is less than 1g/L
or massive transfusions
prothrombin complex concentrate to patients taking warfarin who are actively bleeding.
This should be a consultant-led decision with haematology input.
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Catheterisation
Catheterise the patient to closely monitor urine output hourly!!
if variceal bleeding ((eg known history of liver disease or alcohol excess) =
- Terlipressin
causes vasoconstriction of the splenic artery, reducing blood pressure in the portal system. It is recommended for use in all patients with suspected variceal bleeding = consultant led decision
Prophylactic antibiotic therapy
with suspected or confirmed variceal bleeding.
piperacillin/tazobactam IV
The recommended antibiotic treatment is Ciprofloxacin 1g once daily for seven days
if severe segstaken - blakemore tube
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Glasgow blatchford score before endoscopy
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Endoscopy
Endoscopy should be performed on all unstable patients with severe UGIB immediately after resuscitation when they become STABLE. It should be performed within 24 hours of admission for all other patients with UGIB.
EGD - and electrocautery
w can do clipping and thermal cognation with adrenaline if non vatical bleeding
or if variceal - BAND LIGATION - until then use segstaken - blakemore tube
gastric variceal - cyanoacrylate glue
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rockall score
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Proton pump inhibitor (PPI)
Proton pump inhibitors (PPIs) reduce the amount of acid produced by the stomach. High concentrations of acid increase the probability of re-bleeding
NICE advises that acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) should not be offered to patients before endoscopy with suspected non-variceal upper gastrointestinal bleeding.
in patients undergoing
successful endoscopic haemostasis, give PPI (eg omeprazole
also give ppl in upper PUD bleeding - initially iv
omeprazole 8mg/hr for 72hr
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ongoing GI bleeding and hemodynamic instability refractory to resuscitation needs mesenteric angiography
Angioembolization
Intraarterial vasopressin
Surgery
Indications
Consider if other therapeutic options have failed.
Consider in hemodynamically unstable patients with ongoing bleeding.
Procedure: exploratory laparotomy and surgical hemostasis
suture ligation
if variceal - TIPS - until then use segstaken - blakemore tube
In the context of acute haemorrhage not adequate time for matching what is done ?
O-negative blood is given
what is the risk scoring system of UGIB
Blatchford score is calculated prior to endoscopy . Its principal use is to identify low-risk patients who do not require any intervention (blood transfusion, endoscopic therapy, surgery).
blood urea nitrogen hemoglobin level systolic BP HR presentation with melena presentation with syncope hepatic disease cardiac failure
Scores range from 0-23
score higher than 0 has higher risk for needing a medical intervention in terms of transfusion, endoscopy, or surgery. Scores of 6 or more were associated with a greater than 50% risk of needing an intervention.
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Rockall score post endoscopy
It is important to identify those patients who are at risk of ongoing bleeding and death. . Rockall scores can be calculated both before and after endoscopy, but the post endoscopy provides a more accurate risk assessment. It provides independent risk factors which have been shown to accurately predict the risk of rebleeding and mortality.
age shock comorbidity diagnosis evidence of bleeding
Rockall score of < 3 have a low risk of re bleeding or death and can be considered for early discharge.
Signs of a rebleed:
Rising pulse rate.
• Falling JVP ± decreasing hourly urine output.
• Haematemesis or ‘fresh’ melaena (NB: it is normal to pass decreasing amounts of
melaena for 24h post-haemostasis, as blood makes its way through the GI tract).
• Fall in BP (a late and sinister fi nding) and decreased conscious level.
quick managemnet in hematochezia ?
nasogastric aspirate
what us the quick management for variceal bleeding ?
uncontrolled oesophageal variceal bleeding, a Sengstaken–
Blakemore tube may compress the varices, but should only be placed by
someone with experience.
transjugular intrahepatic portosystemic shunt
diagnosis of h pylori in PPUD
noninvasive testing for H. pylori infection:
Urea breath test
H. pylori stool antigen test
esophageogstroduodenoscopy
biopsy sampling
treatment of PUD?
E.g., avoid NSAIDs, restrict alcohol.
H. pylori eradication therapy with antibiotics and a PPI
Continue acid suppression medication (i.e., PPIs) for 4–8 weeks.
Standard triple therapy PPI, amoxicillin 1 g, and clarithromycin 500 mg (Biaxin) twice daily
