GI Haemorrhage Flashcards
define upper GI bleed
bleeding form the oesophagus, stomach and duodenum
define lower GI bleed
bleeding from the small bowel ad colon
define haematemesis
vomiting of fresh blood from the upper GI tract
what is coffee-ground vomitus?
vomiting of black material which is assumed to be partly digested blood
its presence implies that bleeding has ceased or has been relatively modest
define melaena
passage of dark tarry black stool usually due to an acute upper GI bleed
define haematochezia. what can cause it?
passage of fresh or altered blood per rectum usually due to colonic bleeding
can sometimes be due to profuse upper GI or small bowel bleeding
list the possible causes of haematemesis and melaena
- Peptic ulcer disease
- Erosive gastritis
- Mallory-weiss tear (laceration in mucosa at the junction of the stomach and oesophagus)
- Oesophagitis due to GORD
- Ruptured oesophageal varices
- Vascular abnormalities, such as angiodysplasias
- Gastric neoplasm
what additional questions would you ask a patient presenting with haematemesis and melaena?
- non-specific symptoms of hypovolaemia
- symptoms of chronic blood loss - anaemia symptoms
- heartburn (oesophagitis)
- weight loss - carcinoma
- dysphagia (difficulty swallowing), odynophagia (painful swallowing) - oesophagitis or oesophageal carcinoma
- retching (especially after alcohol binge) - mallory -weiss tear
- abdominal pain
- known liver disease/oesophageal varices
- check drugs - NSAIDs, aspirin, steroids, thrombolytics
which non-specific symptoms of hypovolaemia must you ask about in a patient presenting with haematemesis and melaena?
- faintness
- weakness
- dizziness
- sweating
- palpitations
- dyspnoea
- pallor
- collapse
what would sudden severe abdominal pain in a patient with haematemesis and melaena suggest?
possible bowel perforation
what would intermittent epigastric pain in a patient with haematemesis and melaena suggest?
peptic ulceration
what are the scoring systems used in upper GI bleeds?
Rockall score and Blatchford score
which parameters are measured when calculating a Rockall risk score?
pre-endoscopy: age, systolic BP and pulse rate, comorbidity
post-endoscopy: diagnosis and signs of recent haemorrhage on endoscopy
what does the rockall score indicate?
GI bleed mortality initially
the pre-endoscopy criteria is added to post-endoscopy criteria to calculate the risk of mortality after endoscopy
what is the NICE guidance regarding using scoring systems in acute upper GI bleeds?
calculate Blatchford score first - if score of 0 then consider early discharge
calculate Rockall score post-endoscopy (each centre has their own cut-offs for admission)
what parameters are measured to calculate a Blatchford score in patients with acute upper GI bleeding?
- laboratory results such as haemoglobin and BUN
- history of melaena
- history of cardiac failure
- history of hepatic disease
- recent syncope
- sex
- heart rate
- BP
what are the signs of shock?
- Peripherally cool/clammy
- Cap refill time >2s
- Urine output <0.5 mL/kg/h
- Decreased GCS or encephalopathy
- Tachycardia
- Systolic BP <100mmHg; postural drop >20mmHg
describe the immediate management, step by step, for a patient with a suspected GI bleed with shock
- protect airway and keep NBM. insert 2 large-bore cannulae
- urgent bloods - FBC, U&E, LFT, Glucose, clotting screen, cross-match 4-6 units
- Rapid IV crystalloid infusion up to 1L to maintain BP
- if grade III or IV shock, give blood group specific or O- blood
- correct clotting abnormalities - vitamin K, fresh frozen plasma, platelet concentrate
- if risk of varices, give terlipressin IV 1-2mh/6h and broad-spectrum IV antibiotics
- consider referral to IVU or HDU
- catheterise and monitor urine output (aim for >30 mL/h)
- monitor vital signs every 15 mins until stable, then every hour
- notify surgeons
- urgent endoscopy after adequate resuscitation
what makes a bleed seen on endoscopy ‘high risk’?
active bleeding
adherent clot
non-bleeding visible vessel
what makes a bleed seen on endoscopy ‘low risk’?
flat, pigmented spot or clean base
how are high-risk bleeds due to peptic ulceration treated?
◦ 2 of: clips, cautery, adrenaline
◦ Start PPI
◦ If haemodynamically stable, start oral intake of clear fluids 6h after endoscopy
◦ Treat if positive for H.pylori
how are low-risk bleeds due to peptic ulceration treated?
◦ No need for endoscopic haemostasis
◦ Consider early discharge if patient otherwise low risk
◦ Give oral PPI
◦ Regular diet 6h after endoscopy if stable
◦ Treat if positive for H.pylori
how are gastro-oesophageal variceal bleeds managed acutely?
- endoscopic banding (oesophageal)
- sclerotherapy - causes blood clotting in veins (gastric)
what is the prophylaxis of variceal bleeding in someone with known gastro-oesophageal varices?
- beta blockade (propranolol)
- repeat endoscopic banding
