Upper GI Bleed

Question 1

You are asked to review a 46-year-old male patient in the emergency department who presented with a major upper gastrointestinal bleed. He has a history of alcoholic liver disease.

What is your initial management for this patient?

Answer 1

• Carry out an immediate ABCDE assessment and resuscitation as appropriate, including continuous monitoring and 100% oxygen with a non-rebreathe mask. This should include an airway assessment to gauge the need for intubation.
• Insert at least two large bore IV cannulae and administer fluid boluses as appropriate.
• Activate the major haemorrhage protocol to ensure readily available blood products, and that haematology, porters and the medical team are aware of the patient.
• Take bloods including clotting and cross match. Carry out bedside testing if possible (Haemocue, TEG).
• A focused history and examination of the patient may determine the cause and severity of the bleed:
• Medical history.
• Drug history.
• Previous GI bleeds.
• Peripheral stigmata of chronic liver disease.
• Discuss the patient with the gastroenterologists and theatre team regarding endoscopy as soon as he is stable.
• Consider pharmacological therapy:
• Terlipressin (given the potential for a variceal bleed).
• Reverse anticoagulants if appropriate e.g. vitamin K, prothrombin complex concentrate , protamine (if inpatient on heparin).
• Tranexamic acid.
• Proton pump inhibitor infusion.
• Administer antibiotics if endoscopy intervention includes variceal
  banding.

Question 2

What are the indications for intubation in this patient?

Answer 2

• Severe bleeding leading to airway compromise.
• Severe haemodynamic instability.
• Hepatic encephalopathy/confusion and poor compliance of treatment.
• Need for endoscopic intervention.
• Cardiac arrest.

Question 3

What are the common causes of upper GI bleeds?

Answer 3

• Ulcers (oesophageal, gastric, duodenal): drug causes (NSAIDs), infective (H. pylori) and stress.
• Oesophageal/gastric varices secondary to portal hypertension.
• Mallory-Weiss tear.
• Malignancy.
• Post-surgical.

Question 4

How can the risk of re-bleeding and death be predicted in this patient?

Answer 4

• The Rockall score can be used to assess the risk of mortality and further episodes of bleeding in this patient. It uses five categories, each of which are given a score from 0 to 3:
• Age.
• Presence of shock (heart rate and systolic blood pressure).
• Comorbidities.
• Diagnosis.
• Endoscopy findings.
• A score of >7 suggests a 35% risk of mortality, which is increased if the patient has another episode of bleeding.

Question 5

The patient is having ongoing episodes of haematemesis, and he requires transfer to theatre for an urgent endoscopy. He has a history of varices.

What are the treatment options for this patient?

Answer 5

• Endoscopic variceal band ligation (1st line).
• Endoscopic variceal sclerotherapy.
• Balloon tamponade if the above measures fail.
• Transjugular intrahepatic portosystemic shunt (semi-elective, following stabilisation with balloon tamponade).

Question 6

What are the risk factors for the development of stress ulcers in patients on intensive care?

Answer 6

• Invasive ventilation.
• Severe shock states.
• Deranged clotting.
• Patient with severe burns.
• Neurological trauma e.g. traumatic brain or spinal injuries.
• Pre-existing gastrointestinal ulcers.