Upper GI bleeding Flashcards
Upper GI bleeding is
some form of bleeding from the oesophagus, stomach or duodenum
Presentation of upper GI bleed
Haematemesis
Coffee ground vomiting -vomiting digested blood
Meleana = tarry, black/dark offensive stools - digested blood
Haemodynamic instability - associated with large volume blood loss –> low BP, tachycardia, other signs of shock NB. young, fit patients may compensate well until huge volume of blood lost
Causes of upper GI bleeding
VINTAGE
Varices 5% - oesophageal varices
Inflammation - oesophagitis 5%/gastritis 20%, PUD commonest cause (DU) - 40%
Neoplasia - oesophageal/ stomach cancer <3%
Trauma - Mallory Weiss 10%/ Borhaave’s
Angiodysplasia
Generalised bleeding diathesis - warfarin, thrombolytics
Epistaxis
History/symptoms of pt with upper GI bleed relating to underlying pathology
Dyspepsia, hx of PUD Jaundice/ liver disease in oesophageal varices Dysphagia, weight loss Drugs, alcohol Comorbidities
Findings on examination in upper GI bleed
Signs of CLD - jaundice, spider naevi, caput medusae Shock? - cool, clammy - CR >2 secs - Low BP <100 systolic or postural drop <20 - Reduced urine output <30ml/h - Tachycardia - low GCS PR: meleana
What are the two scoring systems used in upper GI bleed?
Glasgow-Blatchford Score
Rockall Score
What is Glasgow-Blatchford score used for and what are the criteria?
Used in SUSPECTED upper GI bleed on first clinical presentation to help make a plan. Score of >0 indicates risk of upper GI bleed
Drop in Hb Rise in urea Blood pressure Heart rate Meleana Syncopy
Why does urea rise in upper GI bleed?
Blood in the GI tract gets broken down but stomach acid and digestive enzymes - urea is a breakdown product and gets absorbed into the intestines
When is Rockall score used and what are the criteria?
Prediction of rebleed and mortality in patients that HAVE HAD AN ENDOSCOPY - provides percentage risk of rebleed and mortality
Initial score pre-endoscopy
Age
Shock - hypotension, tachycardia
Comorbidities
Final score post endoscopy
Final diagnosis & evidence of recent haemorrhage
e.g. active bleeding, visible vessel, adherent clot
Initial score >3 or final >6 = indication for surgery
Management of upper GI bleed
ABATED
ABCDE approach for immediate resuscitation
Bloods - FBC, U&Es (urea), LFT, clotting (INR), cross match for 2 units of blood
Access - 2x 14G
Tranfuse if remains shocked - group specific or O-
Endoscopy - arrange urgent endoscopy within 24h
Drugs - stop precipitating drugs e.g. NSAIDs, steroids
Principles of transfusion in upper GI bleed
Transfuse with blood product which is necessary and individualised to the patient
Transfuse blood (red packed cells), platelets & clotting factors (fresh frozen plasma) in pt with massive haemorrhage
Platelets given in active bleeding and thrombocytopenia - platelets <50
Prothrombin complex concentrate given to warfarin patients and actively bleeding
Transfusing with more blood than necessary can be harmful to the patient
During urgent endoscopy, the following can be performed to stop bleeding:
Haemostasis of vessel or ulcer Adrenaline injection Thermal/ laser coagulation Fibrin glue Endoclips
Additional steps before/during endoscopy for oesophageal variceal bleeding:
Before: Terlipressin IV & prophylactic antibiotics
During: 2 of: Banding Sclerotherapy Adrenaline Coagulation Balloon tamponade with Sengstaken-Blakemore tube - only used of exsanguinating haemorrhage or failure of endoscopic therapy
What is done if bleeding cannot be stopped endoscopically?
TIPSS or surgery
What is involved in TIPSS
Transjugular intrahepatic porto-systemic shunt
IR creates artificial channel between hepatic vein and portal vein –> reduce portal pressure
Colapinto needle used to created tract through liver parenychma –> expanded using balloon and maintained with stent
Used prophylactically or acutely if bleeding cannot be controlled endoscopically
