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
What cane be used to prevent rebleeding in someone with an upper GI bleed?
IVI omeprazole
For how long should a patient with an upper GI bleed be kept NBM?
24h
Then clear fluids for 24h
Then light diet after 48h as long as no evidence of rebleeding
In an an upper GI bleed, if on endoscopy there is active bleeding or a non-bleeding visible vessel, what is the management?
Admit to ICU and perform endoscopic haemostasis
IVI PPI for 72h - then oral
If haemodynamically stable, start clear fluids 6h post-endoscopy
Test and treat for H.pylori
In an an upper GI bleed, if on endoscopy there is an adherent clot, what is the management?
Endoscopic removal, followed by endoscopic haemostasis
In an an upper GI bleed, if on endoscopy there is a flat area, pigmented spot, or clean base, what is the management?
Consider early hospital discharge after endoscopy if pt. otehrwise stable and low risk
initiate oral intake with regular diet 6h after endoscopy in stable pts
Test and treat for H.pylori
What endoscopic signs make rebleeding more likely in an upper GI bleed?
Active arterial bleeding - 80%
Visible vessel - 50%
Adherent clot/black dots - 30%
What are the indications for surgery after an upper GI bleed?
Severe bleeding or bleeding despite >6units blood
Active or uncontrollable bleeding at endoscopy, or rebleeding
Initial Rockall score >3 or final Rockall score >6
How much does the pressure in portal HTN need to rise by to cause varices?
> 10mmHg
How much does the pressure in portal HTN need to rise by to cause variceal bleeding?
> 12mmHg
What is the mortality associated with each episode of variceal bleeding from portal HTN?
30-50%
What are the pre-hepatic causes of portal HTN?
Portal vein thrombosis
Splenic vein thrombosis
What are the intra-hepatic causes of portal HTN?
Cirrhosis (80% cases in UK) Schistomiasis (commonest worldwide) sarcoidosis myeloproliferative diseases congenital hepatic fibrosis
What are the post-hepatic causes of portal HTN?
Budd-Chiari syndrome
R-sided heart failure
Constrictive HF
Veno-occlusive disease
What are the risk factors for variceal haemorrhage?
Increased portal pressure
Variceal size
Endoscopic features of variceal wall (haemocystic spots)
What are the risk factors for varices?
Alcohol abuse
Cirrhosis
Chronic liver disease
How can variceal haemorrhage be prevented?
B-blockers - propranolol
Endoscopic banding ligation
What should be done for an individual presenting with acute variceal bleeding?
Get help Resus until haemodynamically stable (No 0.9% saline) Correct clotting abnormalities IVI terlipressin Endoscopic banding
