Upper GI Bleeding

Question 1

Clincial features

Answer 1

Presents with

• haematemesis (vommiting fresh blood)
• coffee ground vomitting (altered blood)
• melenea - passing black stools

Question 2

Where is the bleeding?

Answer 2

From oesophagus to distal duodenum

Question 3

Causes

Answer 3

• peptic ulcer- 36%
  -oesophagitis - 24%
  -Gastritis - 22%
  -Duodentitis 13%
  -Varicies 11%
  Malignancy -4%
  Mallory-Weiss tear- alcohol

Question 4

Initial management of acute GI bleed

Answer 4

Is the patient shocked?

• Cool and clammy to touch (nose, fingers, toes) decreased capillary refill
• Pulse > 100bpm, JVP not visible
• systolic BP

Question 5

Glasgow blatchford score

Answer 5

Blood urea (mmol/L)
6·5-7·9 = 2 points
8·0-9·9 = 3 points
10·0-25·0 = 4 points
>25·0 = 6 points

Haemoglobin for men (g/L)
120-129 =1 points
100-119 = 3 points
=100/min =1 point

presentation with melaena = 1 point

presentation with syncope = 2 point

hepatic disease* = 2 point
cardiac failure** =2 point
* Known history, or clinical and laboratory evidence, of chronic or acute liver disease.
**Known history, or clinical and echocardiographic evidence, of cardiac failure

Question 6

How to interpret glasgow blatchford score

Answer 6

Assesses probability for intervention (Blood Transfusion, endoscopy, surgery)

Score 0
Low risk for intervention
Reasonable to manage as outpatient

Score >0
Increased risk for intervention and inpatient management is recommended
However most cases
High risk for intervention

Question 7

Acute management of patient if haemodynamically stable

Answer 7

Insert two big cannulae
Start slow saline IV
Check bloods and monitor vitals + urine output
Consider transfusion if >30% loss of circulating volume

Question 8

Acute management if patient shocked

Answer 8

1. Protect airway and keep Nothing by mouth
2. Urgent bloods, FBC, U&Es, LFTs, glucose, clotting cross match six units
3. Rapid IV crystalloid infusion up to 1L
4. If signs of grade III or IV shick give blood group specific or Rh-ve until crossmatch done
5. Otherwise slow crystalloid infusion
6. Correct clotting abnormalities Vitamin K, FFP, platelet concentrate
7. Consider referral to ICU or HDU and consider CVP line to guide fluid replacement. Aim for >30ml/h
8. Monitor vital signs every 15min until stable, then hourly
9. Notify surgeons of all severe bleeds
10. Urgent endoscopy for diagnsosis + control of bleeding
    - Within 4 hours if variceal bleeding
    - within 24 hours if patient unstable on admission