Upper Gastrointestinal Bleeding Flashcards
How is orthostatic hypertension defined?
Drop of 20 mmHg systolic BP from sitting > standing
AND/OR
Drop of 10 mmHg diastolic BP from sitting > standing
AND/OR
Increase in pulse of >20 bpm from sitting > standing
What is haemetemesis?
Vomiting blood
Fresh/altered, source proximal to ligament of Treitz
Where is the source of blood in melaena?
Proximal to ileocaecal valve
When can an upper gastrointestinal source of blood result in passage of bright red blood per rectum?
Torrential loss
What are many deaths associated with in upper gastrointestinal bleeding?
Decompensation of co-existing medical condition precipitated by acute bleeding event
How can the gastroduodenal artery bleed?
Erosion of stomach ulcer can infiltrate gastroduodenal artery
What are the measures of haemodynamically significant bleeding?
External evidence of blood loss >500 mL Resting tachycardia - If on beta blockers, may not have this Systolic BP <100 mmHg Orthostatic hypotension
Who are high-risk patients in the case of upper gastrointestinal bleeding?
Clinical evidence of recurrent/ongoing bleeding
Syncope
Coexisting illness, especially ischaemic heart disease
What is the management of high-risk patients in the case of upper gastrointestinal bleeding?
Triage to monitored setting
Consider admission to ICU
Multidisciplinary approach
Timely involvement of gastroenterologist and/or upper GI surgeons
What is the immediate management of significant upper gastrointestinal bleeding?
2 large bore IV cannulas, as close to central circulation as possible
Supply of blood must be obtained
- Group and hold
- Crossmatch
Urgent effort to arrive at anatomical diagnosis
How is normovolaemia restored?
Rapid infusion of crystalloids
- Usually 2 L of saline
Transfusion of colloids - plasma substitutes
Packed cells and/or whole blood
Consider central venous pressure monitoring
- Consider doing in HDU, or if going into theatre
Urinary output monitoring with catheter
What are the most common causes of upper gastro-intestinal bleeding?
Peptic ulcer disease Oesophageal varices Gastro-duodenal erosions Mallory-Weiss tear Oesophagitis Upper GI tumour
What questions on history would you ask for a heametemesis presentation?
Alcohol intake Known peptic ulcer with/without surgery NSAID use Chronic liver disease Abdominal aortic aneurysm Anticoagulant medications
What leads to non-operative management of haemetemesis?
Successful endoscopic haemostasis
- Heat coagulation
- Adrenaline injection
- Clips for bleeding peptic ulcer/erosive gastritis
- Variceal ligation
- PPI infusion
- Octreotide infusion for varices
What leads to surgery for haemetemesis?
Failed endoscopic haemostasis and ongoing rebleeding for peptic ulcer
What leads to a “wait and see” approach in management of haemetemesis?
Bleeding stopped on endoscopy but possibility of further bleeding
What is the Blatchford score?
Risk stratification of patients with upper GI bleeding
Higher scores = higher risk
What is the management of acute bleeding from a peptic ulcer, at presentation?
Assess haemodynamic status - Pulse - BP Obtain - FBE - UEC - INR - Blood type - Cross-match Start resuscitation - Crystalloids - Blood products Consider NGT tube placement and aspiration Consider starting treatment with IV PPI while waiting for early endoscopy Perform early endoscopy - within 24 hours Consider giving single 250 mg IV dose of erythromycin 30-60 min before endoscopy Perform risk stratification
Why is IV erythromycin given before an emergency endoscopy?
Speeds up gastric emptying
What is the management of acute bleeding from a peptic ulcer, at early endoscopy?
Perform risk stratification
What is a transjugular intrahepatic portosystemic shunt (TIPS)?
Connect portal vein with hepatic vein with shunt to reduce portal hypertension and its complications, especially variceal bleeding
