Upper GIT haemorrhage Flashcards
Causes of acute upper GIT haemorrhage
- Oesophagus: Oesophageal varices, Mallory-Weiss tear
- Stomach: Gastric ulcer, erosive haemorrhagic gastritis
- Duodenum: Duodenal ulcer, erosive duodenitis
- Other uncommon causes: tumours, stomal or anastomotic ulcers, vascular malformation, oesophagitis or oesophageal ulcers
Typical history of peptic ulcer disease
History of periodic dyspepsia related to meals or excessive analgesic ingestion (Not sensitive or specific)
History given for a mallory-weiss tear
History of an episode of repeated vomiting
In a patient with excessive alcohol intake and known liver disease, what is the likely cause of upper GIT bleeding
oesphageal varices
What is maelena and what does it indicate
- Black tarry stools which is formed by blood mixed with acid
- Indicates that the source of bleeding is in the upper GIT tract
In severely shocked patients, what should be mandatory
- Central venous pressure line and urinary catheter
- Baseline haematolological and biochemical investigations must be urgently requested together with cross-matching of blood
How is the resuscitation of patients with suspected liver disease different to other patients with upper GIT bleed
Patients with underlying liver disease should not be given sodium containing crystalloid solutions. They should be resuscitated only with blood, 5% dextrose, given fresh frozen plasma to replenish clotting factors and receive ocreotide to lower portal pressure
Uses and disadvantages of use of nasogastric tube in patients with upper GIT haemorrhage
- Uses: Early identification of recurrent or continued bleeding, the performance of gastric lavage and emptying the stomach contents before endoscopy
- Disadvantages: Unreliable in detecting rebleeding, uncomfortable for the patient, may cause rather than prevent aspiration in the elderly patients
Diagnostic procedure of choice for upper GI bleeding
Endoscopy
When is urgent endoscopy indicated
-Oesophageal varices are suspected or where there are signs of continuing haemorrhage. High risk patients should undergo endoscopy as soon as they are stabilised
If an urgent endoscopy is not indicated, when should it be performed
-Where urgent endoscopy is not indicated, patients should undergo a full diagnostic endoscopy within 12-24 hours of admission when they are clinically stable and have been fully resuscitated
Forrest classification of peptic ulcers (High risk)
- IA: Spurting blood (visible vessel)
- IB: ooze blood (non-visible vessel)
- IIA: non bleeding visible vessel
- IIB: Adherent clot
Forrest classification of peptic ulcer (low risk)
IIC: pigmented spot
III: clean ulcer base
When is angiography indicated
Indicated in number of patients who continue to bleed and when endoscopy has failed to disclose a likely bleeding site. Bleeding from obscure and uncommon sites such as the liver, pancreatic duct, small bowel and colon may be identified.
What risk stratification score is used in patients with upper GIT bleeding, what score indicates increased risk of bleeding and death
- Rockall risk score
- A total score of over two indicates increased risk of bleeding and death