Upper GI bleed

Question 1

A 64-year old gentleman has been sent to the AMU by his GP with a 2-day history of passing black stool. He has been feeling increasingly unwell but has not had any other symptoms. His PMHx includes HTN, hypercholesterolaemia, 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:

BP: 110/67
Heart rate: 110 bpm
Saturations: 94% on room air
RR: 20
T: 36.9

What further information would be helpful to you when taking a history from this gentleman?

Answer 1

1. Ask about the episode of black stool - how long, quantity, frequency

RFs for upper GI bleed:
* Previous upper GI bleed
* Known atrophic gastritis, GI metaplasia/dysplasia, liver disease, oesophageal disease, known varices
* Use of antiplatelets, anticoagulation, NSAIDs (esp given pt’s OA), SSRIs, steroids

DHx:
I would also want to know what medications the patient is taking (any antiplatelets or anticoagulants). Is the patient taking any iron tablets that could be the cause of the black stool?

SHx:
* Smoking and alcohol history

Question 2

What could be the cause of this gentleman’s black stool?

Answer 2

The most common causes of an upper GI bleed are:
* Peptic ulcer disease (35-50%)
* GI ulcer disease
* Oesophagitis
* Varices
* Malory-Weiss tear
* Upper GI malignancy
* AV Malformations

Or think in therms of anatomical site:

Pharynx
- Vomiting of swallowed blood from a nasal bleed

Oesophagus
- Peptic ulcer disease
- Oesophageal varices
- Mallory-Weiss tear

Stomach:
- Gastritis (alcohol, drug-indiced, biliary, irritant)
- Gastric ulcer
- Gastric carcinoma

Duodenum
- Duodenal ulcer
- Duodenitis

Across all: AV malformations, upper GI malignancy

Question 3

What investigations will you arrange?

Answer 3

Bedside:
* PR exam to see if any evidence of melaena
* HR, BP, SpO2
* 12-lead ECG
* VBG (quick check on lactate and Hb)

Bloods
- FBC (anaemia), U&E (RF), LFTs, Bone profile
- Coagulation screen
- 2x G&S

Imaging
- Endoscopy to identify the cause & give Rx
- Urgency will be determined by the severity of UGIB

Question 4

Do you know of any measures of severity when assessing a pt with a suspected UGIB?

Answer 4

The GBS score (Glasgow-Blatchford bleeding score) is used to stratify upper GI bleeding patients
- A score of 0 identifies low-risk pts who can be suitable for OP management
- Pts 1-7 - generally require admission and consideration for IP endoscopy by the GI team
- GBS > 7 - severe bleed - discuss urgently with senior medical staff

Question 5

What risk score used to identify patients at risk of adverse outcome following upper GI bleed?

Answer 5

Rockall score

Question 6

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.

How will you manage this patient?

Answer 6

• • Activate major haemorrhage protocol if signs of massive haemorrhage
• Pt likely to develop hypovolaemic shock

A
- Ensure that airway is protected (risk of aspiration)
Sit up or lateral position
- Keep suction nearby

B
- Monitor SpO2, RR
- Give high flow oxygen if necessary

Circulation
- Monitor HR, BP, CRT
- 2 x large-bore cannulae
- Give IV crystalloid (500 ml in < 15 min)
- Transfuse if Hb < 70g/L (aim 70-100)

Coagulation
- Correct clotting abnormalities using vitamin K +/- FFP
- Platelet tranfusion if ≤50 x 10^9L
- Continue low dose aspirin, stop/reverse other antiplatelets/anticoagulants

D
- Monitor consciousness levels (hypovolaemic shock/cerebral hypoperfusion
- Monitor tempearture

E
- Thorough exam to identify other signs of bleeding
- To evaluate for signs of liver disease

Medical Mx
- If variceal bleed, I would give terlipressin and broad spectrum ABx
- Consider early ITU involvement
- Keep pt NBM and d/w with the on-call gastroenterology team

Question 7

What clinical signs might lead you to suspect underlying chronic liver disease?

Answer 7

ABCDE-LIVER

• A - Asterixis & Ascites
• B - Bruising (ecchymosis)
• C - Caput Meduase & Clubbing
• D - Dupuytren’s contracture
• E - o(E)dema - hypoalbuminaemia & portal HTN
• L - Leukonychia
• I - Icterus/jaundice
• E - Encephalopathy
• R - Red palms (palmar erythema) & Spider Naevi

Question 8

An endoscopy results shows a bleeding peptic ulcer which is injected and the patient is stabilised. How could you investigate this gentleman for Helyciobacter pylori infection?

Answer 8

Urea breath test
- Production of radiolabeled CO2 from swallowed urea

or

Stool antigen test

If undergoing endoscopy, biopsies can be taken

Question 9

What treatment would you initiate for H. pylori?

Answer 9

Triple therapy
* PPI
* Amoxicillin & Clarithromycin

Question 10

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

Answer 10

• Advice around alcohol & smoking cessation
• Advice re- medications: avoid NSAIDs & antiplatelet meds (balance of risks)
• Continue PPI for a minimum of 6 weeks
• Appropriate safety netting

Question 11

You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover having seen this patient on the acute take. This would be following his initial presentation, prior to any endoscopy.

Answer 11

S – I am handing over a 64 year old male patient with an acute upper GI bleed who is showing signs of hypovolaemic shock. I think he is having a life threatening upper GI bleed.

B – He presented with a two day history of melaena, before passing a further large amount of black stool in A+E.

A – I have obtained IV access and started aggressive fluid management.

R – This gentleman will need an urgent transfusion. I have sent an urgent cross match but have asked the team to have Group O negative blood ready for immediate transfusion if there is further deterioration. He needs to be urgently discussed with the on-call gastroenterology team as he needs an urgent endoscopy to identify the site of bleeding.