Upper GI bleeding Flashcards
(33 cards)
How does upper GI bleeding present?
- Active upper gastrointestinal bleeding most commonly presents presents as bright red haematemesis, coffee ground vomiting, or/and melaena
- Patients with the combination of both haematemesis and melaena typically have rapid bleeding, and their mortality is up to twice that of those with either symptom in isolation
What is haematemesis?
vomiting of bright red blood
What is coffee ground vomiting?
vomiting of dark coloured, granular material resembling coffee grounds
What is melaena?
loose, black, tarry stools with a characteristic offensive odour
What is upper vs lower GI bleeding?
Upper GI bleeding is defined by a bleeding source proximal to the ligament of Treitz, a suspensory muscle attaching to the duodenojejunal flexure
Why does melaena have its distinct colour?
Blood released above the ligament of Treitz is partially digested during passage through the GI tract, accounting for the appearance of melaena
What does hematemesis implY?
normally implies active upper gastrointestinal bleeding
What does coffee ground vomiting indicate?
Coffee ground vomiting usually suggests that the bleeding is less profuse, has ceased, or is intermittent in nature
How does lower GI bleeding present?
Lower GI bleeding usually presents as red or maroon coloured rectal bleeding (haematochezia), although less commonly it may occur where upper tract haemorrhage is profuse or particularly brisk (known as “rapid transit”)
What can meleana also arise from aside from upper GI bleed?
Melaena may also arise from ingested blood, in which case inspection of the nares (nostrils) and oropharynx can identify a non-gastrointestinal source of bleeding, for example epistaxis or gingival bleeding.
Other causes of coffee ground vomiting?
Dark vomitus from small bowel obstruction can be initially mistaken for haematemesis. Additionally, sepsis or myocardial ischaemia may present with vomiting, especially in older people
What are the causes of upper GI bleed?
- Most commonly Peptic ulcers (up to 50% of cases)
- Gastric and duodenal erosions (up to 15%)
- Esophagitis (up to 15%)
- Mallory Weiss syndrome (up to 15%)
- Esophageal varices (up to 10%)
- Rare causes include GI malignancy and vascular malformations
Risk factors for peptic ulcers
Risk factors primarily include irritant drug use (predominantly non-steroidal anti-inflammatory drugs) and Helicobacter pylori infection.
What is Mallory-Weiss syndrome?
A linear tear at the gastro-oesophageal junction which may resolve spontaneously without the need for endoscopic intervention
Esophageal variceal bleed mortality rate
About 30%
Aim of initial assessment in upper GI bleeding
- Determine the severity of bleeding
- Estimate the volume of blood loss
- Assess the potential cause and site of haemorrhage
- Determine the patient’s premorbid fitness, comorbid conditions, and potential contributing medications
- Identify if the patient is at high risk of rebleeding or death and so may require urgent endoscopic, radiological, or surgical intervention.
- Consider whether the patient is suitable for a medical ward, or requires admission to an ICU or HDU.
Score used to assess Upper GI bleed risk and what is it
The Glasgow-Blatchford bleeding score (GBS) is a screening tool to assess the likelihood that a person with an acute upper gastrointestinal bleeding (UGIB) will need to have medical intervention such as a blood transfusion or endoscopic intervention.[1] The tool may be able to identify people who do not need to be admitted to hospital after a UGIB
Symptoms of significant hemorrhage
postural hypotension, dizziness, syncope, palpitations, tachypnea, altered mental state (anxious, aggressive, drowsy, confused, or unconscious, these are stepwise from class 1 to class 4) and cold peripheries are all indicative of significant haemorrhage
How long should you be nil by mouth before OGD?
At least 4 hours
What is blood loss volume classified into?
4 classes
Class 1 <15% (750ml)
Class 4 >40% (greater than 2000 ml)
Lying standing blood pressure in hemorrhage
Measurement of lying and sitting/standing blood pressures can be very helpful, since a postural drop in blood pressure is an earlier indicator of significant blood loss, and occurs before the onset of supine hypotension
Falsely reassuring clinical observations in hemorrhage
- Be aware that patients taking rate controlling medications, particularly beta blockers, may not mount a tachycardic response to blood loss.
- You should also note that reassuring blood pressure readings may in fact be abnormal for those with undiagnosed or poorly controlled hypertension.
Steps to take during major hemorrhage
- Seek senior help early
- Resuscitate and stabilize the patient (A-C)
- IV access (two large bore 16 gauge cannulas)
- Investigations (FBC, U/Es, LFTs, Clotting profile, group and save (consider cross matching 4-6 units of bloods if there is significant bleeding), lactate). It is also important to arrange a chest radiograph and ECG in high risk patients, for example those with a known cardiovascular or respiratory comorbidity.
- IV fluids (Ideally blood, until that’s available give saline or Hartman’s)
Hemoglobin in major hemorrhage
The haemoglobin level on the initial full blood count can be misleading as an indicator of the severity of the bleed. Since haemoglobin is expressed as a concentration, its value will only begin to fall when the circulating volume is restored.
