Upper GI haemorrhage

Question 1

what are some of the causes of GI bleeds?

Answer 1

working top to bottom:
bleeding gastric ulcer, mallory-weiss tears, oesophageal varices, gastric erosions, duodenal ulcer, malignant small bowel tumours, angiodysplasia, polyps or carcinoma of the colon, ischaemic colitis, acute/fulminant UC, diverticular disease, rectal carcinoma, rectal polyps, haemorrhoids

Question 2

what are the relevant points in the clinical Hx?

Answer 2

• Hx of cirrhosis and variceal bleeds
• aspirin / other NSAID use
• alcohol consumptions
• previous gastric ulcers
• previous gastric surgery

Question 3

what constitutes a high risk patient?

what steps are taken in their care?

Answer 3

• 60+
• drop in systolic BP below 100
• presence of severe intercurrent disease e.g suspected liver disease
• Hb below 10g

steps:
admit into high dependency unit –> fluid resuscitation —>inform consultant –> observe for changes indicating rebleeding e.g increaser HR, drop in bp etc –> only sips of water until endoscopy –> endoscopy ithin 12 hrs

attempt to treat bleed endoscopically - if not successful then surgical intervention is required. if nothing is found on endoscopy then observe.

Question 4

who is a low risk patient?

how are they managed?

Answer 4

> 60
previously fit
no indication of hypovolemia
Hb above 10g

steps:
admit onto ward –> allow fluids for first 24hrs then food –> observe for signs of re-bleeding –> arrange for an endoscopy on next elective list.

Question 5

what investigations are performed in suspected GI haemorrhage?
what are the relevant findings?

Answer 5

labs:
bloods: FBC, LFTs, U&E, group and save + crossmatching

ECG and CXR may be considered in elderly with cardioresp disease

Endoscopy when possible:
look to identify the source of bleeding and potentially manage the patient

Question 6

what endoscopic features can place low-risk patients in the high risk category?

Answer 6

active spurting of an artery in an ulcer bed - often need surgery
gastro-oesophageal varices - high mortality of 30%
visible elevated vessel/ protruding adherent clot (Dieulofoy lesion) - high risk of re-bleeding

Question 7

when is surgery required?

Answer 7

• high risk + 1 rebleed
• 2 rebleeds
• unable to resuscitate / risk of exsanguinating haemorrhage –> laprotomy