upper Gi bleed

Question 1

A 64 year old gentleman has been sent to the AMU by his GP with a two day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His past medical history includes hypertension, hypercholesterolemia, angina and osteoarthritis. The medical SpR has asked you to go and see the gentleman on the medical take. The nurse gives you his basic observations:

Blood Pressure: 110/67

Heart Rate: 110 bpm

Saturations: 94% on room air

Respiratory rate: 20

Temperature: 36.9

Answer 1

onset
duration
volume
colour
frequency

any fresh blood occurring before

any past medical history of gastrointestinal problems or liver problems - such as
GASTRITIS
ULCER
VARICIES
ESOPHAGEAL DISEASE

any change n bowel habits or weight loss

DRUG HISTORY - any use of NSAIDS , or anticoagulants , SSRI , on IRON TABLETS

any history of ALCOHOL or SMOKING

Question 2

differentials of upper go bleed

Answer 2

peptic ulcer disease
gastrodudenal ulcers
liver disease - causing variceal haemorrhages
esophagitis mallory weiss tear
upper GI malignancy
AV malformation

gastritis -

Question 3

investigations to arrange ?

Answer 3

bedside - ECG , VBG (lactate)
PR EXAM!!!!!

bloods - fbc , ue , left , crp , coagulation screen , group and save of 2 bottles

radiology - AXR
will need an ENDOSCOPY - severity will determine f the patient requires this immediately or later on ?

Question 4

severity when assessing a patient with a suspected UGIB

Answer 4

Glasgow-Blatchford bleeding score (GBS)

urea
hb
hr
melena
syncope
hepatic disease
cardiac failure

0 identifies low-risk patients

score of 1-7 should generally be admitted for monitoring and consideration of IP endoscopy by the gastroenterology Team.

A GBS score of greater than 7 indicates a severe bleed and patients need to be discussed urgently with senior medical staff.

Question 5

During your assessment the patient passes a large amount of black stool. His blood pressure drops further to 87/49 and his heart rate is 142. The VBG shows that the patient’s Hb is 69 g/L.

Answer 5

Large bore IV access x2 – this is essential as you will be aggressively fluid resuscitating this patient.
SBP >110
100mmhg if its vatical

group and save to cross match 4-8 UNITS OF BLOOD

correct any coagulopathy using vitamin k if they are using warfarin
or FFP

if platelets is less than 50 then transfuse platelets

if variceal - IV terlipressin and IV antibiotics

IV PPI has not shown much benefits - however in my local trust they use it so i would follow local guidelines

KEEP NBM - d/w on call gastro team for urgent endoscopy

call ITU - see if this patient needs admission there i it uncontrolled UGIB - might need sengstaken tube

Question 6

investigate patient has H. pylori

Answer 6

urea breast test
stool antigen test

Question 7

h pylori eradication therapy

Answer 7

high dose PPI and amoxicillin and clarithromycin
which is a 7 day course

if penicillin allergic - metronidazole

Question 8

advice should this man be given regarding his long term management and discharge?

Answer 8

avoid spicy and oily food
avoid drinking alcohol
avoid smoking

avoid NSAIDS and anti platelet medications

safety netting the patient