Upper GI haemorrhage Flashcards
What are the causes of acute upper GI haemorrhage?
Oesophagus: - Oesophageal varices (10%) - Mallory-Weiss tear (10%) Stomach: - Gastric ulcer (25%) - Erosive haemorrhagic gastritis (10%) Duodenum: - Duodenal ulcer (25%) - Erosive duodenitis (5%) Any: - Tumours
Immediate management/resuscitation of upper GI haemorrhage?
- Large-bore IV lines with crystalloid & colloid fluid resuscitation, followed by whole blodd
- Urinary catheter
- Bloods: FBC, U&E, creatinine, INR, LFTs, cross-match
In which cause of upper GI haemorrhage do you NOT give sodium-containing fluids, and why? Which fluids can you give them?
Patients with oesophageal varices secondary to liver disease
Sodium-containing crystalloids may lead to a deterioration of liver function and ascites
These patients should be resuscitated with 5% dextrose, FFPs to replenish clotting factors, Octreotide to lower portal pressure
What is the diagnostic procedure for an upper GI bleed? How can you help prep the patient for this procedure?
Endoscopy
Can empty stomach with nasogastric tube (not routinely indicated)
When is an urgent endoscopy indicated?
- Oesophageal varices are suspected
- Signs of continued haemorrhage
When should high-risk patients get an endoscope done?
Once they are stabilised
When should non-high-risk patients get an endoscope done?
12-24 hours after admission, when clinically stable and resuscitated
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IA
Spurting blood (visible vessel)
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IB
Oozing blood (non-visible vessel)
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IIA
Non-bleeding visible vessel
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IIB
Adherent clot
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade IIC
Pigmented spot
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Grade III
Clean ulcer base
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: High risk grades?
IA, IB, IIA, IIB
Forrest classification of endoscopic stigmata of bleeding peptic ulcer: Low risk grades?
IIC, III
When is angiography indicated in an upper GI bleed?
- When patient continues to bleed and endoscopy fails to find bleeding site
- When endoscopic methods fail to control bleeding, and patient is poor candidate for surgery: NB, must be non-variceal cause
What Rockall score indicates an increased risk of rebleeding and death following an upper GI bleed?
> 2
What are the categories incorporated into the Rockall score?
Age Haemodynamic status: BP + HR Co-morbidities Endoscopic diagnosis Stigmata of recent haemorrhage
Medical treatment of upper GI bleed?
IV PPI’s (change to PO later) - this is to raise the intragastric pH >6 and prevent clot lysis
H. pylori eradication therapy (after stabilised)
Which patients are at risk for rebleeding?
- > 60 y/o
- Shock on admission
- Endoscopic stigmata of recent bleeding (Forrest high risk group)
- Large ulcers (>2cm)
- Ulcers in lesser curve of stomach and posterior duodenal bulb
When are patients at highest risk of rebleeding?
First 48 hours after haemorrhage
Endoscopic methods for control of upper GI bleeding?
- Diluted (1:10,000) adrenalin tamponade injection into tissue surrounding bleeding vessel
- Bipolar thermal coagulation
- Metal clip
Indications for surgery for an upper GI bleed?
- Exsanguinating haemorrhage
- Associated perforation
- Failed endoscopic therapy of actively bleeding, shocked patient
- Recurrent bleeding after endoscopic therapy
- At risk for rebleeding when endoscopy not available
