Management of Acute Upper GI Haemorrhage Flashcards
how might GI bleeding present?
haematemesis (thick, black, blood clotted vomit)
Melaena (thick, black, sticky, blood clotted stool)
How serious is GI bleeding?
can be major life threatening medical emergency
Must be considered severe until proven otherwise
Most are self limiting with no in-hospital re-bleeding
Continued/recurrent bleeding = 30-40% mortality
Death due to complications
what are the most common causes of GI bleeding?
1) duodenal ulcer
2) gastric erosions
3) gastric ulcer
4) varices
5)Mallory-Weiss tear
others = oesophagitis, duodenitis, ulcers, neoplasm etc
what has contributed to the slight decrease in mortality from GI bleeding?
development of endoscopy
discovery of H.pylori
development of omeprazole etc
what is the most important management of GI bleeding?
recuscitation:
A.irway
B.reathing
C.irculation
first thing = Airway protection:
- oxygen
- IV access (largest bore cannula - grey one)
- fluids
what is the 100 rule?
assesses severity of the haemorrhage considered severe if: - systolic BP <100 - pulse >100 - Hb <100 - age >60 - comorbid disease - postural drop in BP
who have good and bad compensation for bleeding?
diabetics = bad
young people = compensate then crash hard
Older = bad
People taking beta-blockers = bad
what are the 3 functions of endoscopy in GI bleeding?
identify cause
therapeutic manoeuvres
Assess risk of rebleeding
what is the Rockall scoring system?
point scoring system for assessing risk of rebleeding in GI haemorrhage patients
what is the Blatchford score?
point scoring system for assessing risk of rebleeding in GI haemorrhage patients
Uses different criteria than Rockall system
what are the benefits of the Blatchford score over the Rockall score?
it doesn’t require endoscopy
what are the ranges of Blatchford score and what do they mean?
0-1 = low risk bleed 2-5 = intermediate risk bleed 6+ = high risk bleed
what does bleeding from a peptic ulcer look like?
blood spurting into the lumen
what are the 3 criteria used to diagnose recent haemorrhage?
active bleeding
overlying clot
visible vessel
what treatments are available for peptic ulcer bleeding?
endoscopic treatment (high risk ulcers)
Acid suppression
Surgery
H.pylori eradication (secondary prevention)
what possible treatments can be delivered via endoscopy?
injection (adrenaline - causes balance to favour thrombotic over thrombolysis so pepsin and acid don’t dissolve clot)
heater probe coagulation
Combinations (injection + heater probe/clip = best)
Clips
Haemospray
what is haemospray?
powder spray which is applied to the area of the ulcer to stop the bleeding by absorbing all the water from the area causing a clot to form
Used if clips etc don’t work
what is acid suppression?
PPI eg. omeprazole Used after bleeding has stopped Prevents rebleeding Reduces need for surgery Everyone gets it
when is surgery performed in peptic ulcer bleeding?
if adrenaline injection/heater probe/clips don’t control the bleed
OR
rebleed which is not controlled by endoscopic therapy (injection, clips etc)
who is likely to get varices?
people with liver disease (chirrosis)
what are the risk factors for varices bleeding?
portal pressure >12mmHg
varices >25% of oesophageal lumen
presence of red signs
degree of liver failure (childs A<b></b>
what is mortality like from varices bleeding?
25-50%
due to complications (sepsis, liver failure)
how do varices arise in cirrhosis?
as cirrhosis progresses, the resistance of the liver to flow from the portal vein increases increasing portal vein pressure, causing back pressure in all surrounding vessels and at the G.O junction, drainage above this is usually through azygous vein and portal vein (posteriorly), when pressure rises the blood tries to find another way back to systemic circulation, so goes upwards into the azygous causing distension of oesophageal veins
when would you expect varices in a bleeder?
known history of cirrhosis with varices, alcohol excess, viral hepatitis, metabolic/autoimmune liver disease, abdominal sepsis/surgery
what would be seen on examination in varices?
stigmata of chronic liver disease
what does an oesophageal varice look like?
big, distended, spongey vein inside the oesophagus
what are the aims of management in varices bleeding?
resuscitation
haemostasis
prevent complications
prevent deterioration of liver
what should be considered in varices treatment?
coagulopathy (low platelets in cirrhosis/alcoholics) CVP monitoring parenteral vitamins antibiotics (sepsis risk) unexpected pathology (eg. perforated D.U) hypoglycaemia (liver dysfunction) replace K, Mg and PO4 delirium treatments
how can haemostasis be achieved?
terlipressin (vasopressin analogue) endoscopic variceal ligation (banding) sclerotherapy sengstaken-blakemore balloon TIPS
what is teripressin?
vasopressin prodrug
splanchic vasoconstrictor
beneficial in renal perfusion
better than vasopressin, statins, octreotide
what is sclerotherapy?
injection of chemical into a vessel to obliterate it
what is sengstaken-blakemore balloon?
tube inserted via nose/mouth, balloon inflates inside stomach to restrict flow to varices
what is TIPS?
Transjugular intrahepatic portosystemic shunt
treats gastric bleeding
creates communication beween inflow and outflow veins in liver
