UGI bleeding Flashcards
Clinical features ugi bleed
haematemesis, coffee ground
melena, black and tarry
a raised urea may be seen due to the ‘protein meal’ of the bloodfeatures associated with a particular diagnosis e,g,
oesophageal varices: stigmata of chronic liver disease
peptic ulcer disease: abdominal pain
UGI bleed Oesophageal causes
Oesophageal varices
Oesophagitis
Cancer
Mallory Weiss tear
Oesophageal varices features
- large volume of fresh blood.
- Swallowed blood may cause melena.
- haemodynamic compromise.
- May stop spontaneously but re-bleeds are common until appropriately managed.
Oesophagitis features
- Small volume of fresh blood, often streaking vomit.
- Malena rare.
- Often ceases spontaneously.
- Usually history of antecedent GORD type symptoms.
Cancer features
- small volume of blood, except as a preterminal event with erosion of major vessels.
- dysphagia and constitutional symptoms such as weight loss.
- May be recurrent until malignancy managed.
Mallory Weiss tear features
- Typically brisk small to moderate volume of bright red blood following a bout of repeated vomiting.
- Malena rare.
- Usually ceases spontaneously.
Gastric causes
Gastric ulcer
Dieulafoy lesion
Diffuse erosive gastritis
Gastric ulcer
- Small low volume bleeds are more common so would tend to present as iron deficiency anaemia.
- Erosion into a significant vessel may produce considerable haemorrhage and haematemesis
- Pain soon after meals, not relieved by eating, eating makes it worse . As food passes into the stomach it irritates the ulcer (due to acid secretion)
Dieulafoy lesion
Often no prodromal features prior to haematemesis and melena, but this arteriovenous malformation may produce quite a considerable haemorrhage and may be difficult to detect endoscopically
often symptomatic in men with alcohol histories, cardiovascular disease including hypertension, diabetes, or chronic kidney disease.
Diffuse erosive gastritis
Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise
Duodenual causes
Duodenal ulcer
Aorto-enteric fistula
Features of Duodenal ulcer
- usually posteriorly sited and may erode the gastroduodenal artery
- may present with haematemesis, melena and epigastric discomfort.
- pain 2-3h after meals (when the pyloric sphincter relaxes to allow the acidic food contents into the duodenum), pain relieved by eating.
Aorto-enteric fistula
In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality.
Risk assessment
the Glasgow-Blatchford score at first assessment helps clinicians decide whether patient patients can be managed as outpatients or not
the Rockall score is used after endoscopy- provides apercentage risk of rebleeding and mortality
Resuscitation
- ABC, wide-bore intravenous access * 2
- platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
- fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
. prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
