Upper GI Bleeding Flashcards
What might be a presentation of someone with variceal bleeding?
- History of alcoholic liver disease
- Haematemesis (fresh red blood)
- Low BP
- Feels light headed
- Peripherally cold
- Pale
- Cap refill 5 seconds
What would you want to investigate in someone with variceal bleeding?
- HR
- GCS
- Urine output (fluid status)
- PMH
- How much haematemesis and what colour (if coffee then not a sign anything is wrong on its own or acute bleed)
- Any malaena
What does high HR and low BP indicate?
Class 3 shock, 50% blood volume lost
What is malaena?
Passage of loose black stool indicating fresh blood aka black diarrhoea (check with rectal exam)
How would you manage someone with an acute variceal bleed?
- 2 large bore IV cannulas (worried about haemodynamic instability, needs fluid)
- Take bloods incl. cross matching if need to give bloods
- IV fluids
- ABG
- Insert catheter for hourly UOP
- Keep NBM if need to get endoscopy
- Frequent observations
What clotting value do you want to aim for?
INR < 1.5
How would you treat someone with acute variceal bleeding?
- Stop offending drugs
- Need blood?
- Correct clotting
- Platelet transfusion
- Consider abx if risk of aspiration or varices
- Supportive care - often stop bleeding on their own by the time put endoscope in
When do you transfuse a patient according to the restrictive strategy?
When Hb < 70 g/L
When do you transfuse a patient according to the liberal strategy?
When Hb < 90 g/L
How would you treat a non-variceal bleed (peptic ulcer)?
Proton pump inhibitors (pantoprazole infusion) - useful in healing process
What medication would you use to treat a variceal bleed?
Terlipressin - reduces blood supply to varices (causes vasoconstriction) or co-amoxiclav
What is the most common cause of UGI bleeding?
Peptic ulcer
What are the causes of UGI bleeding?
1) Mallory-Weiss tear
2) Oesophagitis/gastritis
3) Oesophageal varices
4) Peptic ulcer
5) Malignancy
6) Drugs
7) Angiodysplasia
8) Aorto-enteric fistula
What are the top 4 causes of UGI bleeding?
Peptic ulcer, oesophagitis, Mallory-Weiss tears and oesophageal varices
What causes oesophagitis?
Acid reflux or doxycycline
What is the most common type of peptic ulcer?
Duodenal
What should you always ask about in someone with a peptic ulcer?
NSAID history
What is malignancy more likely to present with than bleeding?
Pain and dysphagia
What is angiodysplasia?
- Abnormal vessels in mucosa and sub-mucosa of the UGI tract which suddenly bleed bc they are fragile esp. in people with heart conditions
- More common in > 60 years
- Secondary to mucosal ischaemia or low grade obstruction of mucosal veins
- Possible link with aortic valve disease (Heyde’s syndrome)
- Usually radiate out from central vessel
- Can just be red spots
What drugs can cause UGI bleeding?
- NSAIDs
- Aspirin
- Anticoagulants (clopidogrel)
- Steroids
What is the Blatchford score useful for?
Identifies patients that require clinical intervention e.g. endoscopy or blood transfusion (how emergent they are)
What does a Blatchford score ≥ 6 mean?
There is > 50% risk they will need an intervention
What can be mistaken for malaena?
Dark brown solid stool due to iron
When does someone with a severe bleed (Blatchford ≥ 6 or ongoing haemodynamic instability) need an OGD?
Urgent one resuscitated (need protected airway)
When does someone with mild/moderate bleed or malaena need an OGD?
Within 24h of admission
What should you give 30 mins before an OGD and why?
250mg IV erythromycin to get blood out of GI tract so can see better
What kind of treatments can you give to stop bleeding when doing an endoscopy?
- Clip an exposed vessel in the middle of a peptic ulcer and inject adrenaline straight into the ulcer
- Burn vessels
- Banding e.g. of pseudo-polyp - will scar on its own, stops bleeding upstream immediately
How many types of therapy should you give to stop bleeding?
2
How do you manage a patient after an OGD?
- Continue PPI, terlipressin and abx
- Rockall score
- Clear fluids after 1h
- Light diet after 6h
- Monitor for signs of re-bleeding
- Only keep NBM for one day
- Keep patient on ward
What do you do when the bleeding can’t be controlled?
Put in coils, embolise or involve surgery
What is the aim of the Rockall score?
To identify risk factors to predict mortality and risk of re-bleeding
What Rockall score carries a good prognosis?
< 3
What Rockall score carries a high risk of mortality?
> 8
What other things would you do to treat a peptic ulcer?
- Check and eradicate H. pylori
- Omeprazole 40mg OD/BD 8 weeks
- Repeat scope in 6-8 weeks if gastric ulcer
- Stop smoking
- Risk of malignancy (not direct)
What other things would you do to treat varices?
- Propranolol or carvedilol
- Endoscopic banding every 2-4 weeks
What is a Mallory-Weiss tear?
- GOJ (gastro oesophageal junction) laceration secondary to retching
- 80-90% stop spontaneously
How do you treat a Mallory-Weiss tear if it doesn’t stop spontaneously?
Same as peptic ulcer - clipping, burning, injecting adrenaline
What are peptic ulcers commonly related to?
- H. pylori
- NSAIDs
- Hypersecretory (gastrinoma)
What classification is used to decide who needs therapy for peptic ulcers at the time of endoscopy?
Forrest’s
What is used to test for H. pylori?
- CLO (biopsy + rapid urease test)
- Urea breath test
- Serum IgG and stool antigen
What is the treatment for H. pylori?
7 day triple therapy of PPI + amoxicillin + metronidazole
What are oesophageal varices due to?
Portal hypertension due to chronic liver disease (first bleeds carry 25-50% mortality)
Where else can varices be found?
Stomach, rectum, duodenum
What may be needed to treat oesophageal varices?
TIPSS (transjugular intrahepatic portosystemic shunt)
What type of cancers are > 90% of gastric cancers?
Adenocarcinoma
What are risk factors for gastric cancer?
- H. pylori
- Smoking
- Preserved food
- Genetics
Why do gastric cancers have poor outcomes (5 year survival 20%)?
They often grow into lumens which don’t really transmit pain
What are two common types of oesophageal cancer?
Squamous cell carcinoma and adenocarcinoma (late presentation is common)
What are 3 risk factors for oesophageal cancer?
- Barrett’s
- Achalasia
- Betel nuts
What is gastritis (unlikely cause of bleeding) associated with?
- NSAIDs
- Alcohol
- TB
- H. pylori
