Upper GI Bleed

Question 1

Causes

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

Present

Answer 2

Haematemesis (vomiting blood)
“Coffee ground” vomit. This is caused by vomiting digested blood that looks like coffee grounds.
Melaena, which is tar like, black, greasy and offensive stools caused by digested blood
Haemodynamic instability occurs in large blood loss, causing a low blood pressure, tachycardia and other signs of shock. Bear in mind that young, fit patients may compensate well until they have lost a lot of blood.

The patient may have symptoms related to underlying pathology:

Epigastric pain and dyspepsia in peptic ulcers
Jaundice for ascites in liver disease with oesophageal varices

Question 3

Scoring

Answer 3

Glasgow-Blatchford Score
The Glasgow-Blatchford Score is used as a scoring system in suspected upper GI bleed on their initial presentation. It scores patient based on their clinical presentation. It establishes their risk of having an upper GI bleed to help you make a plan (for example whether to discharge them or not).

Using an online calculator is the easiest way to calculate the score. A score > 0 indicates high risk for an upper GI bleed. It takes into account various features indicating an upper GI bleed:

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

TOM TIP: The reason urea rises in upper GI bleeds is that the 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.

Rockall Score
The Rockall Score is used for patients that have had an endoscopy to calculate their risk of rebleeding and overall mortality. It provides a percentage risk of rebleeding and mortality. Again, use an online calculator to calculate the score. It take in to account risk factors from the 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 4

Treatment

Answer 4

A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 large bore cannula)
T – Transfuse
E – Endoscopy (arrange urgent endoscopy within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)

Send bloods for:

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

TOM TIP: “Group and save” is where the lab simply checks the patients blood group and keeps a sample of their blood saved in case they need to match blood to it. “Crossmatch” is where the lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary.

Transfusion is based on the individual presentation:

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

There are some additional steps if oesophageal varices are suspected, for example in patients with a history of chronic liver disease:

Terlipressin
Prophylactic broad spectrum antibiotics

The definitive treatment is oesophagogastroduodenoscopy (OGD) to provide interventions that stop the bleeding, for example banding of varices or cauterisation of the bleeding vessel.

NICE recommend against using a proton pump inhibitor prior to endoscopy, however you may find senior doctors that do this.