Management of Acute Upper GI Haemorrhage Flashcards
What is haematemesis?
Blood in the vomit - upper GI bleeding
What is melaena
Blood in the stool - A sign of Upper GI bleeding
What is GI bleeding?
A serious medical emergency until proven otherwise
What are the majority of GI bleeds
Self limiting with no in-hospital rebleed
What is the mortality rate for patients with continued or recurrent bleeding?
30-40%
What can cause upper GI bleeding
duodenal ulcer gastric erosions gastric ulcer varices Mallory -Weiss tear (repeated vomiting and then the appearance of blood) Oeophagitis Erosive duodenitis neoplasm stomal ulcer oesophageal ulcer
How can you control the blood pressure of a patient?
IV access to give fluids
What venflon should be used with GI bleeding?
Grey venflon
What is the 100 rule?
systolic BP 100bpm
Hb 60
Comorbid disease
Postural drop in blood pressure
How many litres of circulating volume do you have?
5
How much can you afford to lose at a young age?
4
How much volume can you afford to lose at an older age?
1
What do you do if there is a high suspicion of GI bleed and what does this tell you?
Endoscopy
to identify the cause
to manage the cause
assess the risk of rebleed
What scoring system is used for to measure the risk of a upper GI rebleed ?
What is it scored on?
Rockall RIsk Scoring system age pulse SBP Presence or absence of co-morbidity
What does the Blatchford Scoring system determine?
Why is this advantageous of the Rockall RIsk Scoring System
The high risk of GI bleeding patients
It does not require an endoscopy
What do we do for patients that score 0-1 on the Blatchford Scoring system?
Require an outpatient endoscopy
What are the 3 high risk stigmatas of recent haemorrhage
Active bleeding/ oozing
Overlying clot
Visible vessel
How can you achieve haemostasis
Get a balance of thrombosis and thrombolysis
What are the endoscopic treatments of peptic ulcers?
Injection (best is 1/10000 adrenaline - gives a tamponade effect and a pharmacological effect of vasoconstriction)
Heater probe coagulation
Combinations
Clips - apply to achieve haemostasis
Haemospray - new device used as rescue therapy when the rest has not worked
What is the combination therapy?
Injection and heater probe coagulation
What is acute variceal bleeding
Varices are dilated submucosal veins, most commonly detected in the distal esophagus or proximal stomach
What causes variceal bleeding?
Cirrhotics
Complications such as sepsis and liver failure
What does intervention do in acute variceal bleeding?
Reduced bleeding related mortality
What happens as the resistance in the portal vein increases
The pressure increases and so the flow changes to try and find an alternative route back into the systemic system
When do you suspect varices in a bleeder?
Known history of cirrhosis with varices
History of chronic alcohol excess
Chronic viral hepatitis infection
metabolic or autoimmnue liver disease - intra-abdominal spesis/ surgery
What causes leukonychia?
Chronically low protein levels
What can portal hypertension cause
Spider naevi
Ascites
Encepalopothy
Leukonychia
What are the aims of management of variceal bleeding?
Resuscitation Haemostasis Prevent complication of bleeding Prevent deteriorating liver failrure Prevent rebleed
How do we achieve coagulopathy
Plasma donor and give Vitamin K
Why do we always give antibiotics to patients with variceal bleeding
people with cirrhosis - overall improves their mortality
How do we achieve haemostasis is varices?
Terlipressin (vasopressin analogue)
Endoscopic variceal ligation (banding)
Sclerotherapy - now not used as much due to high complications.
Sengestaken-Blakemore balloon - emergency situations
TIPS - in radiology - stent in the liver to reduce pressure in portal vein
What is Sengstaken- Blakemore Tube
it is a balloon into the stomach that is pulled back against the gastro-oesophageal junction causing increased pressure and it will tamponade
TIPS
Transjugular intrahepatic portosystemic shunt (TIPS). This is a procedure to create new connections between two blood vessels in your liver. This can decrease pressure in the veins and prevent bleeding episodes from happening again.
Why is propranolol used in variceal bleeds?
To reduce the pressure in the portal system
What happens if the hepatic function remains poor even after TIPS
Consider a transplant
