Upper GI Bleed Management

Question 1

What to consider if the A-E approach

Answer 1

IV fluid resuscitation - aim for SBP ~100

If massive blood loss - transfuse blood, FFP, platelets as per local massive haemorrhage protocol

Blood transfusion if Hb <7 in variceal bleed or <8 in non-variceal bleed

The patient must be haemodynamically stable before endoscopy

Question 2

Specific things to do in examination

Answer 2

Signs of causes - i.e. chronic / decompensated liver disease

PR exam - melaena

Catheterise - monitor UO

Question 3

What bloods to do

Answer 3

FBC - blood loss
U&E - urea raised in GI bleeds
LFTs - varicose risk 
G&S/crossmatch 
Clotting - coagulopathy common in liver disease
Glucose

Question 4

What investigations to do once stable

Answer 4

OGD

CXR and AXR - for aspiration, obstruction

Question 5

Specific treatment of an acute variceal bleed

Answer 5

Suggested by history / signs / results consistent with chronic liver disease or portal hypertension:

1. Terlipressin - splanchnic vasoconstrictor which reduces portal blood flow
2. Prophylactic IV abx
3. Endoscopic intervention - variceal band ligation

Question 6

Specific treatment of a non-variceal bleed

i.e. Peptic ulcer, mallory-weiss tear, oesophagitis

Answer 6

1. IV PPI

2. Endoscopic intervention - adrenaline injection, clips, thermocoagulation

Question 7

What to do in all patients with a GI bleed

Answer 7

Keep NBM
Transfuse as above
Stop any anti platelets or anticoagulants
Treat any concurrent issues i.e. encephalopathy, alcohol withdrawal

Correct any clotting abnormalities:

• Warfarin - prothrombin complex concentrate + vitamin K
• DOAC - dabigatran, apixiban and rivaroxaban have a reversal agent but prothrombin complex concentrate if not available
• Platelets <50x10^9 - platelet transfusion
• INR high but not on warfarin - vitamin K if INR >1.5 +/- FFP if INR >2
• Fibrinogen <1g/L - cryoprecipitate

Question 8

State some other less commonly used interventions for GI bleeding

Answer 8

Balloon tamponade with Sengstaken-Blakemore tube
Interventional radiology (embolisation)
Surgical intervention
Transjugular Intrahepatic PortoSystemic Shunt (TIPSS)

Question 9

What scoring systems are used in GI bleeding

Answer 9

Glasgow-Blatchford Score - pre-endoscopy (assesses likelihood patient will need intervention

• 0 = manage as outpatient
• > 1 = manage as inpatient
• Haemoglobin
• Urea
• SBP
• Sex
• HR
• Melaena
• Recent syncope
• Hx of liver disease or heart failure

Rockall Score - post-endoscopy - mortality risk

• <2 - good prognosis
• > 8 - high mortality risk
• age
• shock
• comorbidities
• diagnosis
• evidence of bleeding

Question 10

Preventing further bleeding in oesophageal varies

Answer 10

1. Propranolol - B-b reduces portal venous pressure
2. Variceal banding
3. TIPSS - allows blood flow out of portal system into hepatic vein
4. Liver transplant

Question 11

Preventing further bleeding in peptic ulcer

Answer 11

1. PPI
2. H. pylori eradication if +ve
3. Avoid precipitants i.e. NSAIDs