Upper GI bleed

Question 1

What extra things would you do in A-E assessment?

Answer 1

• Palpate abdomen
• look for stigmata of chronic liver disease
• PR

Question 2

What are your differential diagnoses?

Answer 2

• Peptic ulcer
• Severe oesophagitis / oesophageal erosions
• Bleeding oesophageal varices
• Mallory-Weiss tear
• Malignancy
• Dieulafoy’s lesion
• Vascular malformations
• Aorto-enteric fistula (commonest at approx. 5 years post-surgery. Approx. 2% risk)

Question 3

After performing your initial assessment, what would you go on to do next?

Answer 3

• Escalate, inform senior
• liaise with gastro consultant
• if pt deteriorates, liaise w/ anaesthetists/surgeons
• cont resus until seniors arrive

Question 4

What are some of the most common causes of peptic ulcer disease?

Answer 4

• H. pylori
• NSAID use
• Alcohol
• Steroid use
• Zollinger-Ellison syndrome (gastrin-secreting tumour causing multiple ulcers)

Question 5

What investigations would you carry out in this case?

Answer 5

Bedside tests: 12 lead ECG

Haematological tests: FBC, U+Es, LFTs, Clotting, Cross match (2-4 units), Venous blood gas (lactate in particular)

Radiological tests: Erect Chest X-ray (to look for pneumoperitoneum in the case of a perforated viscus). Endoscopy. Consider CT scan, USS abdomen (liver)

Question 6

Do you know of any scoring systems for Upper GI bleeds?

Answer 6

Glasgow- Blatchford:
- Risk stratify – predicts the need for hospital-based intervention
- Use acutely but not as good as Rockall in predicting overall mortality
- NICE recommend at time of first patient assessment
- Score 0 = home
- Score >0 = endoscopy
- Score >5 (6 and up) = same day endoscopy

Rockall:
- Prognostic tool, pre and post-endoscopy scores
- NICE recommend full Rockall Score AFTER endoscopy
- Scores below 2 have a very low mortality
- Scores 8 or higher have a mortality of >40%

Question 7

What would be the definitive management of this patient?

Answer 7

OGD

Inform:
- gen surg reg
- gastro
- endoscopy department/coordinator

Patient management:
- reassess using A-E
- book case with endoscopy
- d/w pt, make NBM
- transfuse if needed
- consider IV terlipression if oesophageal varices are most likely cause
- hold anticoags and reverse if required (prothrombin complex concentrate for warfarin)
- stop NSAIDs
- NO PPI before endoscopy for non-variceal UGIB

Tx:
- OGD once stablised
- For non-variceal bleed: clips +/- adrenaline, thermal coag w/adrenaline, fibrin/thrombin + adrenaline
- For variceal bleed: band ligation for oes var, injection of N-btyl-2-cyanoacrylate for gastric
- if not successful, urgent interventional radiology or surgical management