GI bleed management

Question 1

Upper GI bleed management (Non variceal)

Answer 1

• Glasgow Blatchford Score – on admission
• Rockall Score – pre and post endoscopy
• Resuscitation: 2 large bore cannulas, IV fluid bolus, G&S + X-match (transfuse if needed), NBM
• PPI (erosive oesophagitis / gastritis): start IV for 3 days then PO
• Consider NG lavage to identify upper GI bleed
• OGD – within 24 h*
• haemostasis: embolization, clipping, sclerotherapy
  Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment. + IV PPI post op
• if rebleeds: 2nd OGD + therapy
• 3rd bleeds: surgery

*if unable to identify source with OGD consider other Ix e.g. arteriography, colonosopy, capsule endoscopy, scintigraphy

Question 2

Upper GI bleed management (Variceal)

Answer 2

• ABC: 2 large bore cannulas, fluid bolus, G&S + X-match*
• vasoactive agents: terlipressin or octreotide
• prophylactic antibiotics: NICE recommend quinolones
• OGD: endoscopic variceal band ligation is superior to endoscopic sclerotherapy.
• Sengstaken-Blakemore tube (minnesota tube) if uncontrolled haemorrhage (cannot do OGD) -> insert tube and reassess after 24 h max
• Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
• Post-endoscopy: start ppx for future variceal bleed: propranolol

*resuscitate if needed: packed RBC +/- FFP

Question 3

Lower GI bleed management

Answer 3

• Resuscitation: 2 large bore cannulas, IV fluid bolus, transfuse if needed, NBM
  Investigations:
• bloods  FBC (Hb, RBC), clotting, G&S + X-match, CRP, ESR; NG tube lavage if suspect UGI bleed*;
• Colonoscopy 1st line if bleed settled; If unstable, offer angiography (CT or percutaneous); Proctosigmoidoscopy for haemorrhoids; Consider CT abdo and RBC nuclear scintigraphy
• Treatment: haemostatic techniques – embolization, adrenaline injections, bipolar coagulation or haemoclipping;
  If still uncontrolled, consider surgery: localised segmental intestinal resection or subtotal colectomy (useful in UC)

*pts with haematochezia and haemodynamically unstable: consider UGI bleed = OGD