Upper GI bleed

Question 1

Causes of upper GI bleeds?

Answer 1

Oesophageal varices

Mallory-Weiss tear, which is a tear of the oesophageal mucous membrane

Ulcers of the stomach or duodenum

Cancers of the stomach or duodenum

Question 2

Presentation of Upper GI bleeds?

Answer 2

Haematemesis

“ground coffee” vomit - caused by vomiting digested blood

Melaena - tar like, black, greasy stools

Haemodynamic instability (large blood loss) : low blood pressure, tachycardia, signs of shock. young fit patients may compensate well until they’ve lost a lot of blood.

Question 3

What scoring system is used for suspected GI bleed?

Answer 3

Glasgow-Blatchford Score - establishes the risk of having an upper GI bleed to help you make a plan

Question 4

Components of the Glasgow-Blatchford score?

Answer 4

Online calculator

A score > 0 indicates high risk for an upper GI bleed

• Drop in Hb
• Rise in urea
• Blood pressure
• Heart rate
• Melaena
• Syncopy

Question 5

What happens to urea levels in GI bleeds?

Answer 5

Urea rises

Blood in the GI tract gets broken down by the acid and digestive enzymes - one of the breakdown products is urea and this urea is then absorbed in the intestines.

Question 6

Rockall score?

Answer 6

Used for patients that have had an endoscopy

to calculate their risk of rebleeding and overall mortality (online calculator)

takes into account risk factors from clinical presentation and endoscopy findings such as:

• Age
• Features of shock (e.g. tachycardia or hypotension)
• Co-morbidities
• Cause of bleeding (e.g. Mallory-Weiss tear or malignancy)
• Endoscopic stigmata of recent haemorrhage such as clots or visible bleeding vessels

Question 7

Management for upper GI bleeds?

Answer 7

ABATED

A - ABCDE approach to immediate resuscitation

B - Bloods

A - Access (ideally 2 large bore cannula)

T - Transfuse

E - Endoscopy (arrange urgent endoscopy within 24 hrs)

D - Drugs (stop anticoagulants and NSAIDs)

Question 8

What bloods would you order?

Answer 8

• Haemoglobin (FBC)
• Urea (U&Es)
• Coagulation (INR, FBC for platelets)
• Liver disease (LFTs)
• Crossmatch 2 units of blood

Question 9

“Group save” vs “crossmatch” blood?

Answer 9

Group save - lab checks the patients blood group and keeps a sample of their blood saved in case they need to match blood to it

Crossmatch - lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary

Question 10

Transfusion points to remember?

Answer 10

Transfuse blood, platelets and clotting factors (fresh frozen plasma) to patients with massive haemorrhage

Transfusing more blood than necessary can be harmful

Platelets should be given in active bleeding and thrombocytopenia (platelets <50)

Prothrombin complex concentrate can be given to patients taking warfarin that are actively bleeding

Question 11

Definitive treatment for upper GI bleed?

Answer 11

Oesophagogastroduodenoscopy (OGD) to provide interventions that stop the bleeding, for example banding of varices or cauterisation of the bleeding vessels