W3 Acute Upper GI Haemorrhage Flashcards
List most common 5 causes of an acute upper GI bleed.
- duodenal ulcer
- gastric erosions
- gastric ulcer
- varices
- Mallory-Weiss tear
List 5 rarer causes of acute upper GI bleed.
- oesophagitis
- erosive duodenitis
- neoplasm
- stomal ulcer
- oesphageal ulcer
What tends to cause a Mallory-Weiss tear?
Excessive vomiting or coughing
What is the “100 rule”?
- it signifies poor prognostics
- systolic BP <100mmHg
- pulse >100/min
- Hb <100 g/l
- age >60
- comorbid disease
- postural drop in bp
What response is poor in diabetics?
autonomic response
What is purpose of endoscopy for acute upper GI bleed?
- identify cause
- therapeutic manoeuvres
- assess risk of rebleeding
What does the Rockall Risk scoring system assess?
-mortality risk of patient with acute upper GI bleed
What does Rockall Risk scoring system score based on?
- age
- pulse
- systolic BP
- co-morbidity
- diagnosis
- stigmata
What is immediate treatment for patient with acute upper GI bleed?
- resuscitation: ABC (airway, breathing, circulation)
- airway protection
- oxygen
- IV access
- fluids
- then endoscopy
What does the Blatchford Score assess?
The likelihood of a patient with an UGIB needing medical intervention (endoscopy/blood transfusion) and need to stay in hospital.
What does the Blatchford Score score on?
- blood urea
- hb levels
- systolic bp
- Other:
- pulse
- presentation with melaena
- presentation with sycnope
- hepatic disease
- cardiac failure
What PPI is recommended for acid suppression in patient with acute UGIB?
-IV omeprazole
What drug is administered if stigmata of cirrhosis/known liver disease to patient with UGIB?
-terlipressin
Why administer omeprazole in upper GI bleed?
-helps facilitate platelet aggregation cos creates a neutral pH
What are indications for blood transfusion?
- Shock (pallor, cold nose, systolic BP <100, pulse >100)
- Hb <100g/l in patients with recent/active bleeding
Why always large-bore IV cannulae in acute UGIB?
To be able to restore lost blood volume with saline/blood transfusion.
What are 3 stigmata of recent haemorrhage during endoscopy?
- active bleeding/oozing
- overlying clot
- visible vessel
How can patients with acute upper GI bleed present?
- malaena
- haematemesis
- patients are sometimes haemodynamically unstable when large bleed and in shock
List 5 types of endoscopic treatment of peptic ulcers bleed.
- adrenaline injection
- heater probe coagulation
- combinations of injection and heater probe coagulation
- clips
- haemospray
What are potential causes of clot dissolution in an ulcer bleed?
- acid in lumen
- pepsin in lumen
- fibrinolysins in blood stream (e.g. drugs)
What should always be checked in patient with acute UGIB due to peptic ulcer?
- presence of H.pylori bacteria
- prevention of infection
How does haemospray work?
- Haemospray sprayed over open wound
- when it comes in contact with blood the powder absorbs water and forms a cohesive, adhesive mechanical barrier over the bleed
Why is adrenaline injection used to slow/stop bleeding?
Because its acts as a vasoconstrictor and reduces blood flow in that area
What are risk factors of acute variceal bleeding?
- portal pressure >12mmHg
- varices >25% oesophageal lumen
- degree of liver failure
Why does acute variceal bleeding have such a high mortality rate of 25-50%?
Due to complications e.g. sepsis, liver failure
What is portal hypertension commonly caused by?
cirrhosis
How can portal hypertension cause oesphageal varices and name the exact veins?
- Blood flow through portal vein can be diverted due to the high pressure and flow back through anastomoses between portal venous system and systemic venous system.
- In oesophageal varices, blood can flow back through the left gastric vein and through the oesophageal veins and drain into the azygous vein
- the periesophageal venous plexus veins are not designed for that high pressure and so can become tortuous and dilate
What findings when taking patient history would make you suspicious of varices in a bleeder?
- chronic alcohol excess
- chronic viral hepatitis infection
- metabolic or autoimmune liver disease
- intra-abdominal sepsis/surgery
- cirrhosis with varices
List 6 clinical signs of liver disease, in particular alcoholic cirrhosis.
- spider naevi
- leukonychia
- palmar erythema
- ascites
- jaundice
- encephalopathy
What is encephalopathy?
Brain disease/malfunction
What are the aims of management of variceal bleeding?
- resuscitation
- haemostasis
- prevent complications of bleeding
- prevent deterioration of liver function
- prevent early re-bleeding
List 5 mechanisms to achieve haemostasis in acute variceal bleeding.
- terlipressin
- endoscopic variceal ligation (banding)
- sclerotherapy
- sengstaken-blakemore balloon
- TIPS
What is sclerotherapy?
Injection of agent into blood vessel or lymph vessel that causes it to shrink
What is terlipressin?
vasopressin prodrug
What is a prodrug and why are they useful?
- A biologically inactive compound that is metabolised into an active drug when administered into the body
- improves bioavailability of drugs that are poorly absorbed from GI tract
What class of drug is vasopressin?
Antidiuretic
In what vessels does terlipressin predominantly induce vasoconstriction?
splanchnic vessels
How is Sengstaken-Blakemore Tube used?
SB tube is inserted into nose/mouth down into oesphagus and stomach and balloons are inflated to put pressure on bleeding varices and stop bleeding
When is Sengstaken-Blakemore Tube used?
When endoscopic haemostasis treatment fails
What is the TIPS procedure?
- Transjugular Intrahepatic Portosystemic Shunt
- shunt placed between portal vein and hepatic vein to treat portal hypertension and uncontrollable gastric variceal bleeding
When bleed stops what is treatment for oesophageal varices?
Propranolol and a banding programme
What does parenteral mean?
Administered into the body not through the mouth or alimentary canal
What should be considered to be administered in acute variceal bleeding?
- CVP monitoring (portal pressure vs CVP)
- coagulopathy -> maybe administer Fresh frozen plasma/platelets/vitamin K
- parenteral vitamins
- hypoglycaemia
- replace K+, Mg2+, PO4 2-
- antibiotics
- unexpected pathology e.g. DU
- delirium tremens
What is initial endoscopic therapy treatment in acute peptic ulcer bleed?
- adrenaline injection
- or heater probe thermo-coagulation
- or clips
What is treatment plan of acute peptic ulcer bleed if bleeding stops after endoscopic treatment?
- omeprazole 80mg iv + 8mg/hr/72hrs iv
- H.pylori eradication and course of oral PPI
What is treatment plan of acute peptic ulcer bleed if bleeding doesn’t stop after endoscopic treatment?
-surgery
What is treatment plan of acute peptic ulcer bleed if there is a re-bleed after haemostasis by endoscopic treatment is achieved?
- omeprazole 80mg iv + 8mg/hr/72hrs iv
- another attempt of endoscopic therapy
- if unsuccessful then surgery
What is initial treatment in acute oesophageal variceal bleed?
- resuscitation
- antibiotics
- terlipressin
- OGD +/- EVL
What is treatment plan of acute oesophageal varices bleed if bleed stops after initial treatment?
- propranolol
- banding programme
Why are non-selective beta blockers used in treatment of portal hypertension?
- By blocking beta-1 receptors in the heart cardiac output is decreased which decreases portal blood flow
- By blocking beta-2 receptors there is splanchnic vasoconstriction due to unopposed alpha-adrenergic activity on the vessels thus reducing portal blood flow
What is treatment plan of acute oesophageal varices bleed if bleed continues after initial treatment?
- EVL or SB tube
- if unsuccessful then TIPSS
