Upper GI bleeding Flashcards
Common causes of Upper GI bleeding
Peptic ulcer disease (40%)
gastritis (20%)
Mallory-Weiss tear (10%)
Oesophageal varices (5%)
What is the Rockall score?
prediction of re-bleeding and mortality in patients with upper GI bleed
Initial Rockall score pre-endoscopy
age
shock (BP, pulse)
comorbidities
Final Rockall score post-endoscopy
active bleeding
visible vessel
adherent clot
Pathophysiology of oesphageal varices
Portal HTN → dilated veins at sites of porto-systemic
anastomosis: L. gastric and inferior oesophageal veins
30-50% with portal HTN will bleed from varices
Mortality rate of oesphageal varices
25% - ↑ with severity of liver disease.
Causes of portal HTN
pre-hepatic: portal vein thrombosis
hepatic: cirrhosis, schistosomiasis, sarcoidosis
post-hepatic - Budd-Chiari, RHF, constrict pericarditis
1st and 2nd line prevention of bleed in oesphageal varices
1st line: β-blockers, repeat endoscopic banding
2nd line: TIPSS
Transjugular Intrahepatic Porto-Systemic Shunt (TIPSS)
- creates artificial channel between hepatic vein and
portal vein → ↓ portal pressure. - Colapinto needle creates tract through liver parenchyma and
maintained by placement of a stent. - Used prophylactically or acutely if endoscopic therapy
fails to control variceal bleeding.
Overview of management of upper GI bleeding
1. Resuscitate blood if remains shocked 2. variceal bleed management 3. maintenance 4. urgent endoscopy 5. post-endoscopy
Resuscitation of upper GI bleed patient
- head-down
- 100% O2
- IV crystalloid infusion up to 1L
- Bloods - FBC, U +Es (increase urea), LFTs, clotting, ABG, glucose
Medical management of variceal bleed
- terlipressin IV
2. prophylactic Abx (e.g. ciprofloxacin)
Options for initiating haemostasis of a vessel or an ulcer via endoscopy
- adrenaline injection
- thermal/laser coagulation
- fibrin glue
- endoclips
Varceal bleeding management via endoscopy
I. 2 of:
1. banding,
2. sclerotherpay (injecting salt into vessel, causing its collapse)
3. adrenaline,
4. coagulation
II. balloon tamponade with Sengstaken-Blakemore tube
III. TIPSS if bleeding can’t be stopped endoscopically
Post endoscopy management of upper GI bleeding
- omeprazole
- keep NBM for 24h
- daily bloods
- H.pylori testing
- stop NSAIDs, steroids etc.