General surgery Flashcards
Initial assessment of an upper GI bleed
- Obtain a quick history - AMPLE (Allergies, Medication, PMH, Last ate/drank, Events leading up to addmission)
- Check for previous bleeds, liver status, known ulcers
- Assess for signs of hypovolaemic shock - tacycardia, hypotension, low urine output (catheterise), cool peripheries
Presenting symptoms of upper GI bleed
- Haematemesis - (either red blood or coffee ground emesis)
- Melena (black tarry stool)
What is haematemesis?
Haematemesis is defined as bloody vomit originating from a site proximal to the distal duodenum. Haematemesis can either be frank (pre-stomach) or coffee gound (post-stomach).
What are the two most common causes of an upper GI bleed?
- Ulcer bleed
- Variceal bleed
Causes of upper GI bleed
- Oesophageal origin
- Varicies (secondary to portal hpertension)
- Oesophagitis
- Mallory-Weiss tear
- Oesophageal cancer
- Gastric origin
- Peptic/duodenal ulcer (secondary to H.pylori or NSAID use)
- Gastritis (secondary to NSAID or alcohol use)
- Angiodysplasia
- Gastric cancer
Upper GI bleed Airway
- Secure patients airway
- Place hypotensive patients head down to aid cerebral perfusion
- Suction may be required to clear blood/vomitus
- Consider NP airway to facilitate suction
Upper GI bleed Breathing
- Obtain SpO2
- Give supplemental high flow O2 15L/min (may be helpful for confused, agitated, elderly patients with poor cerebral function)
Upper GI bleed Circulation
- Measure BP and heart rate and monitor for signs of shock
- Obtain IV access
- x2 wide-bore cannula (14G)
- Aggressive fluid resuscitation 1L crystalloid solution STAT
- Send off urgent bloods - FBC (ectent of anaemia and platelets), LFTs (pre-existing liver disease), U&Es ( co-existing AKI, urea rise), clotting/coagulation screen and ABG
- Cross match blood at least 4 units RCC
- O -ve blood should be given if blood is needed before cross match available
- Other considerataions if likely variceal bleed
- Prophylactic antibiotics
- Terlipressin IV 1mg
- Arrange for a 12 lead ECG and assess
What would a significantly high urea with normal creatinine indicate in an UGI bleed?
Severe UGI bleed
Urea is the end metabolic product fo protein hydrolysis. When blood that is rich in haem and other plasma proteins is present in the GI tract, it mimics a heavy protein meal, and urea is produced.
For a patient who is actively bleeding how would you to determine whether to give a platelet transfusion or FFP?
- With a platelet count <50 x 10^9/L, offer platelet transfusion
- With aPTT/PT >1.5 greater than normal, offer FFP
GI bleed Disability and Exposure
- Consider catheterisatoin for accurate fluid balance
- Assess pateints using Glasgow Blatchford bleeding score (pre-endoscopy) to assess for urgency of UGIE
- Urgent referral to gastroenterology or surgery for upper GI endoscopy
The Glasgow Blatchford bleeding score uses the following parameters:
- Haemoglobin <12.9(M), <11.9(F)
- Urea >6.5
- Systolic blood pressure <110mmHg
- Heart rate ≥100bpm
- Presenting with melaena
- Presenting with syncope
- Hepatic disease
- Cardiac failure
Specific causes of upper GI bleeding may be suggested by the patient’s symptoms:
- Peptic ulcer: Upper abdominal pain
- Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia
- Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis
- Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, abdominal distention (ascites)
- Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia
What can be done to control haemorrhage of oesophageal varicies?
- Thermal coagulation
- Thromin injection with adrenaline or banding
- Baloon tamponade
What are the three main disorders encompassed by the term iscahemic bowel disease?
- Acute mesenteric isahcemia
- Chronic mesenteric isachemia (intestinal angina)
- Ischamic colitis
