Upper GI Bleeding Flashcards
what are the clinical features of an upper GI bleed?
Haematemesis - often bright red but can be coffee ground.
Melena
Raised Urea
If variceal then may have signs of chronic liver disease.
If peptic ulcer then may have abdominal pain.
What are the causes of upper GI bleeding?
Peptic ulcers (most common),
Oesophageal varicies,
Oesophagitis/duodenitis,
Mallory weiss tear (tear in oesophagus which occurs after heavy retching or vomiting),
Gastric cancer
What are the oesophageal causes of an upper GI bleed and their features
Oesophageal varices - Large volume of blood, haemodynamic instability.
Oesophagitis - Small volume of blood, often history of GORD.
Cancer - Often small volume of blood unless preterminal erosion of vessel.
Mallory Weiss tear - Following repeated vomiting, usually ceases spontaneously.
What are the gastric causes of an upper GI bleed and their features?
Gastric ulcer - Usually small bleeds overtime so iron def anaemia.
Cancer - Frank haematemesis,
Dieulafoy lesion - AV malformation often no prodrome.
Diffuse erosive gastritis - usually underlying NSAID use
What are the duodenal causes of an upper GI bleed and their features?
Duodenal ulcer - may erode gastroduodenal artery.
Aorto-enteric fistula - rare but fatal
What are the risk assessments used in an Upper GI bleed?
Glasgow-Blatchford used at first assessment (determines whether management can be done as outpatient)
Rockall score is used after endoscopy
What are the features of the Glasgow’s Blatchford score?
Urea,
Hb,
Systolic BP,
Pulse > 100,
Melaena,
Syncope,
Hepatic disease,
Cardiac disease.
If score 0 then can consider early discharge.
What is the resuscitation for upper GI bleeds?
A-E exam, insert 2 wide bore cannulas, and send bloods for Hb, urea, coag, LFTs and G&S.
Transfuse blood when Hb <70.
Transfuse platelets when < 50
FFP to patients with fibrinogen less than 1g/litre or INH > 1.5.
If on warfarin then give Vit K and prothrombin complex concentrate.
What is the initial management of variceal bleeding?
Terlipressin and broad spectrum antibiotics (quinolones).
What are the different endoscopic therapies for an upper GI bleed?
Adrenaline injection (causes vasoconstriction but only temporarily so does require adjunctive treatment)
Heater probe (Cauterise small bleeds)
Endoscopic clips (big bleeds)
Haemostatic powders (temporarily coagulates, used when initial therapy is failing and you need time)
What treatment can be done if an upper GI bleed hasn’t been successfully treated endoscopically.
Radiological embolisation of a bleeding vessel.
Emergency surgery (very rare).
For variceal bleeding - Transjugular intrahepatic portosystemic shunts (TIPS) or sengstaken-blakemore tube.
What is the management of a patient with an Upper GI bleed who is aspirin or NSAIDS or clopidogrel/DOAC
Aspirin or NSAIDs - Stop NSAIDs and aspirin but can continue aspirin after haemostasis has been achieved.
DOAC/clopidogrel - stop and then assess risk once haemostasis is achieved.
What is the prophylaxis and prevention of re-bleeds for varices
Beta blockers like propanolol, endoscopic variceal band ligation (should be performed at two weekly intervals until varices have been eradicated)
