Acute upper GI haemorrhage Flashcards
What is haematemesis?
Vommiting blood
What is Melaena?
Blood in faeces
What causes death in GI bleeding?
Usually complications rather than exsanguination.
What percentage of GI bleeds are self limiting with no in hospital re bleeding?
80%
What is the mortalitiy rates of patients with continued or recurrent bleeding?
30-40%
What are the causes of upper GI bleeding?
Duodenal/gastric ulcers Varicies Malory weiss tear Oesophagitis Neoplasm Stromal ulcer
How do you manage a patient with a GI bleed?
ABCDE
Resus- saves their life. Airway protection, oxygen, IV access, Fluids.
When stable you can stop the bleed
What is the 100 rule fr poor prognostic group?
Systolic BP <100mmHg Pulse >100 beats/min Hb<100g/l age >60 Comorbid disease Postural drop in BP
Diabetic have a poor autonomic response. What does this mean in terms of GI beed?
They cannot maintain there BP and deteriorate fast
Beware people on beta blockers also.
What is an OGD and why would it be used following resuscitation in a GI bleed?
Oesophageal-gastroduodenoscopy.
Identify cause, therapeutic manovres, assess risk of re-bleeding.
What is the rockall risk scoring system?
Identify patients at risk of adverse outcomes following an upper GI bleed.
Considers: Age, pulse, Systolic BP, comorbidity, diagnosis and evidence of bleeding.
Scored 0-11 with the highest being the most at risk
What is the Blatchford score?
The Glasgow-Blatchford Bleeding Score (GBS) helps identify which patients with upper GI bleeding (UGIB) may be safely discharged from the emergency room. Any of the 9 variables, if present, increase the priority for admission (and likelihood of need for acute intervention).
What are the signs of recent haemorrhage?
Active bleeding/oozing
Overlying clot
Visible vessel
What is the treatment for bleeding peptic ulcers?
1) Endoscopic treatment (high risk ulcers)
2) Acid suppression (IV)
3) Surgery
What is the secondary prevention of bleeding peptic ulcers?
H pylori eradication
How can bleeding peptic ulcers be treated endoscopically?
1) Injection with adrenaline
2) Heater probe coagulation
3) Clips
4) Combination
5) Haemospray- if you can’t see anything. Emergency last resort
How does haemospray work?
When it comes into contact with blood the powder absorbs water and acts cohesively and adhesivley forming a mechanical barrier over the bleeding site. Does’t cause much secondary damage so you can repeat endoscopy later and provide definitive treatment
How are bleeding ulcers treated with acid suppression?
IV omeprazole.
Often given post endoscopic treatment as it reduces rebleeding, mortality and the need for surgery
What happens if you try endoscopic therapy and the patient begins bleeding again?
You have one more endoscopy attempt and if the bleeding continues then you must go to surgery/interventional radiology while they are still fit enough for the anasthetic.
What is given post endoscopic treatment for a bleeding peptic ulcer?
Omeprazole 80mg IV and then 8mg per hour for the next 3 days.
Then H pylori eradication as necessary and a course of oral PPI
If you have cirrhosis and oesophageal varicies, what are chances you will have a varaceal bleed within 2 years?
19-40%
What are the risk factors for bleeding oesophageal varicies?
Portal pressure >12mmHg
Varacies >25% of the oesophageal lumen
Presence of red signs
Degree of liver failure (Child’s score A-C where A is mild and C is severe)
Why do people die from oesophageal varacie bleeds?
Complications: Sepsis and liver failure
What are red spots?
Red spots on the varacies due to muccosal thinning
What is the pathophysiology of oesophageal varacies?
Portal hypertension due to liver disease.
Causes the back up of blood in the portal vein and left gastric artery which anastamoses with the azygous vein. => Increased pressure and dilation in the azygous vein
Who are the most common people to get varacies?
Know history of cirrhosis with varices
History: of alcohol excess, chronic viral hepatitis, metabolic or autoimmune liver disease or intra-abdominal surgery/sepsis
What causes portal thrombosis?
Can be intra-abdominal surgery
What are some of the systemic signs of liver disease?
Spider naevi Palmar erythema Leukonychia Ascites Jaundice Encephalopathy (confused and drowsy)
How are bleeding oesophageal varicies treated?
Varaceal band
What are the aims in managing a GI bleed?
Resuscitation Haemostasis Prevent complications of bleeding Prevent deterioration of liver function Prevent early re-bleeding
What can cause splenomegaly?
portal hypertension
What can lead to coagulopathy?
low platelets, Lack of vitamin K, drugs.
Treat with fresh frozen plasma or platelets
Can liver disease cause low levels of faulty platelets?
Yes
Why is it important to monitor central venous pressure in a GI bleed?
You don’t want to over resuscitate as this may increase the bleeding. Increasing central venous pressure will increase portal venous pressure
What should you give to someone initially suffering a GI bleed?
1) Platelets/Fresh frozen plasma
2) Paraentral vitamins
3) Antibiotics
Check for hypoglycemia, potassium, magnesium and phosphate.
Check for unexpected pathology
What is Delirium Tremens?
Delirium tremens (DTs) is the most severe form of ethanol withdrawal manifested by altered mental status (global confusion) and sympathetic overdrive (autonomic hyperactivity), which can progress to cardiovascular collapse
How can you achieve haemostasis when someone is having a varaceal bleed?
1) Terlipressin (vasopressin analogue and will restrict blood flow to the gut and reduce bleeding
2) Endoscopic banding
3) Sclerotherapy is only used when the patient has had multiple bands and has scaring
4) Sengstaken
Blakemore balloon. Temporary fix
5) TIPS
What is Terlipresin and how is it used?
Vasopressin prodrug and is given bollus IV 1-2mg 4 hourly
Splanchnic vasoconstrictor and helps renal perfusion.
Better than vasopressin, somatostatin.
How many bands can you deploy at once?
Up to 7
What is Sclerotherapy?
Produces coagulation. A chemical, the sclerosant, is injected into a vein to entirely obliterate it.
When is a Sengstaken-Blakemore Balloon used?
When there has been failure of endoscopic haemostasis.
Push balloon into the stomach and inflate it. Pull back. This stops blood flowing up from the stomach into the oesophagus.
What is the TIPS procedure?
Insert a wire into the jugular vein -> SVC -> IVC -> hepatic vein.
You push the wire through the hepatic parenchyma into the portal vein.
Deploy a balloon and a stent which decompresses the portal vein from ~20mmHg to 2-3mmHg. Provides a shunt to bypass the liver
When is the TIPS procedure used?
When the patient has known liver cirrhosis and uncontrollable bleeding varicies.
When the varacies stops bleeding, what are the next steps?
Propranolol to reduce systemic BP
Banding programme to have other varacies banded electively
What happens if the banding fails and you get a re bleed
One more endoscopic attempt. and if the bleed continues you do a TIPS procedure. If there hepatic function is then poor they may be considered for transplant
If some one initially presents with a varaceal bleed what are the first steps?
Resusitate
Antibiotics
Terlipressin and early endoscopy
