Upper GI bleeds Flashcards
What are the 2 presenting symptoms that would indicate an upper GI bleed?
Haematemesis
Melaena
What history should be taken from someone presenting with an upper GI bleed?
Previous bleeds? Dyspepsia or ulcers? Known liver disease or oesophageal varices? Dysphagia, vomiting and weight loss? Check drug and alcohol use Serious comorbidity
What things should be looked for on examination in someone with an upper GI bleed?
Signs of chronic liver disease PR for melaena Shock symptoms Peripherally shut down? Low GCS Poor urine output Tachycardic or hypotensive postural drop in BP Rockall risk score
What are the signs to look for when considering liver disease?
- leuconychia, Terry’s nails (white proximally, distal 1/3 reddened by telangiectasias), clubbing, palmar erythema, hyperdynamic circulation, dupuytren’s contracture, spider naevi, xanthelasma, gynaecomastia, atrophic testes, loss of body hair, parotid enlargement, hepatomegaly
What are the common causes of an upper GI bleed?
Peptic ulcers (40%) Mallory-Weiss tear Oesophageal varices Gastritis/gastric erosions Drugs - NSAIDs, aspirin, steroids, thrombolytics, anticoagulants Oesophagitis Duodenitis Malignancy No obvious cause
What are the rarer causes of an upper GI bleed?
bleeding disorders portal hypertensive gastropathy aorto-enteric fistula angiodysplasia haemobilia Dieulafoy lesion Meckel's diverticulum Peutz-Jeghers syndrome Osler-Weber-Rendu syndrome
How can you tell if a patient with an upper GI bleed is in shock?
Cool and clammy + cap. refill >2s Pulse >100 JVP <1cm Systolic BP <100 Postural drop in BP Urine output <30ml/h
If a pt with an upper GI bleed is NOT in shock, what is the management?
Insert bilat wide bore cannulas
Start slow saline IVI
Check bloods, monitor vital signs and urine output
aim to keep Hb >8g/dL
If a pt with an upper GI bleed IS in shock, what is the management?
Protect airway NBM 2 large broe cannulas FBC, U&E, LFT, glucose, clotting csreen Cross match 6 units High flow O2 Rapid IV crystallod infusion upto 1L Blood transfusion if remains shocked, otherwise slow saline infusions Correct clotting abnormalities CVP line to guide fluid replacement Catheterise and monitor urine output Monitor vitals constantly until stable, then hourly Notify surgeons of all severe bleeds Urgent endoscopy for diagnosis
What is the acute drug therapy used after endoscopy for a severe upper GI bleed?
Omeprazole - 80mg stat IV
Followed by 8mg/h for 72h
What is the management of someone with an upper GI bleed due to varices?
Resus then endoscopy
Terlipressin 2mg SC qds
If massive bleed or bleeding continues - Sengstaken-Blakemore tube for balloon tampenade
A bleed is the equivalent of a high protein meal so start treament to avoid encephalopathy
Omeprazole 40mg PO to help stress ulceration
When should endoscopy be performed for an upper GI bleed?
Within 4h of suspected variceal bleeding
Within 12-24h if shocked on admission or significant co-morbidity
What bacterium shoudl be checked for in all patients presenting with an upper GI bleed?
H. pylori
What % of people who rebleed after an upper GI bleed will die?
40%
What are the signs of a rebleed following an upper GI bleed?
Rising pulse rate
Falling JVP +/- decreasing hourly urine output
Haematemesis or melaena
Fall in BP and decreased consciousness level
