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Flashcards in FN: Upper GI bleed Deck (17):
1

History


Previous bleeds
Dyspepsia, known ulcers
Liver disease or oesophageal varices
Dysphagia, wt. loss
Drugs and ETOH
Co-morbidities

2

O/E

Signs of Chronic liver disease
PR: melaena
Shock?
• Cool, clammy, CRT >2s
• Reduced BP (<30ml/h)
• Reduced GCS

3

Common causes

PUD: 40% (DU commonly)
Acute erosions/gastritis:20%
Mallory-Weiss ear:10%
Varices: 5%
Oesophagitis:5%
Ca stomach/oesophagus:<3%

4


Oesophageal Varices →

• Portal HTN → dilated veins @ sites of proto-systemic anastomosis: L.gastric and inferior oesophageal veins
• 30-50% with portal HTN will bleed from varices
• Overall mortality 25%: increased with severity of liver disease

5

Causes of Portal Hypertension:

PRE-hepatic
Hepatic
Post-hepatic

6

Pre-hepatic

Portal vein thrombosis
Hepatic: cirrhosis (80% in UK), schisto (commonest worldwide), sarcoidosis

7

Hepatic

Cirrhosis (80% in UK), schisto (commonest worldwide), sarcoidosis

8

Post-hepatic:

Budd-chiari, RHF, constrict preicarditis

9

Management of blled

1. Resuscitation
2. Give blood if remain shocked
3. Variceal bleed
4. Maintenance
5. Urgent Endoscopy
a. haemostasis of vessel or ulcer
b. Variceal bleeding
6. After endoscopy

10

Resuscitation

• Head-down
• 100% O2, protect airway
• 2 x 14G cannulae + IV crystalloid infusion up to 1L
• Bloods:
→FBC, U + E (increase urea), LFTs, clotting, x-match 6u, ABG, glucose

11

Blood if remains shocked

• Terlipressin IV (splanchnic vasopressor)
• Prophylactic ABX: e.g. ciprofloxacin 1g/24h

12

Variceal bleed

• Terlipressin IV (splanchnic vasopressor)
• Prophylactic ABX: e.g. ciprofloxacin 1g/24h

13

Maintenance

• Crystalloid IVI, transfuse if necessary (keep Hb >10)
• Catheter + consider CVP (aim for >5cm H2o)
• Correct coagulopathy: vit K, FFP, platelets
• Thamine if EtOH
• Notify surgeons of severe bleeds

14

Haemostasis of vessel or ulcer:

• Adrenaline injection
• Thermal/laser coagulation
• Fibrin glue
• Endoclips

15

Variceal bleeding:

• 2 of: banding, sclerotherapy, adrenaline, coagulation
• Balloon tamponade with Sengstaken – Blakemore tube
• TIPSS

16

After endoscopy

• Omeprazole IV + continuation PO (reduces re-bleeding))
• Keep NBM for 24h → clear fluids → light diet @ 48h
• Daily bloods: FBC, U+E, LFT, clotting
• H.[ylori testing and eradication
• Stop NSAIDS, steroids etc.

17

Indications for surgery

• Re-bleeding
• Bleeding despite transfusing 6u
• Uncontrollabel bleeding at endoscopy
• Initial Rockall score >3 or final >6
Open stomach find bleeder and underrun vessel.

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