How does upper GI bleeding present?
Haematemesis
Coffee ground vomiting
Melaena
- black, runny stools
What constitutes the upper GI?
Mouth
Oesphagus
Stomach
Duodenum
List some of the causes of upper GI bleeding.
Peptic ulcer Oesophagitis Gastritis Duodenitis Varices Malignancy Mallory- Weiss tear - a tear in the mucous membrane where the gastro-oesophageal membrane Other
Name some causes of peptic ulceration.
Hypergastinaemia
H.Pylori
NSAIDs
How is upper GI bleeding managed?
Resuscitate if required
- venflons and fluid
Risk assessment and timing of endoscopy
Drug therapy and transfusion
How and when does a patient with upper GI bleeding need resuscitation?
If the BP is low and the heart rate is high
IV access gained for fluids and bloods
Check Hb and urea
Lie them flat and given them oxygen
What are the risk assessment categories and related timings of endoscopy?
High risk - emergency endoscopy Moderate risk - admit and next day endoscopy (most patients) Low risk - out patient management
What is the Rockall Score?
Predicts the mortality for upper GI bleeding
What components are assessed when predicting mortality with the Rockall score?
Age Shock - pulse - systolic bp Co-morbidities
What admission risk markers are assessed with the Glasgow Blatchford Score (GBS)?
Blood urea Haemoglobin Systolic blood pressure Pulse Presentation with melaena Presentation with syncope Hepatic disease Cardiac failure
When should the prognostic score be used?
Glasgow Blatchford Score used for initial assessment
Full Rockall score after endoscopy
What are the stigmanta of bleeding?
High risk of rebleeding - active bloodclot - NBVV Moderate risk of rebleeding - clot formation Low risk of rebleeding - dot - clean base
What endoscopic therapy can be used for treatment of upper GI bleeding?
Adrenaline injection to constrict the blood flow
Heater probe
Endoscopic clips to clip the open vessels shut
Thrombin injection to promote clotting
Laser (ablation - burn the open wounds shut)
List the categories of treatment available for upper GI bleeding.
Endoscopic therapy Radiological embolisation (endovascular) Emergency surgery (rarely needed) Drug theapy Blood transfusion
Which drugs are useful in treatment of upper GI bleeding?
IV PPIs
- reduces rebleeding and mortality post-endoscopy
What do you do if the patient is on antiplatelets or anticoagulants?
Aspirin
- continue low dose after bleeding once haemostasis is achieved (add PPI)
Stop NSAIDs
NOAC/warfarin
- discuss risk/benefit with CV team once haemostasis is achieved
When are blood products used in upper GI bleeding?
Restrictive transfusion if Hb <7-8g/dL
Platelet transfusion is active bleeding and platelet count is <50x109/L
Fresh frozen plasma if INR >1.5
PT complex concentrate is on warfarin and they are actively bleeding
What is the mortality rate of a ruptured variceal bleed?
30-40%
How are unruptured variceals managed?
Endoscopic banding
or
Beta-blocker drugs (to reduce the portal pressure)
TIPS
How is acute variceal bleeding managed?
Resuscitation - restore circulating volume - transfusion if Hb<7-8g/dL - consider airway protection Endoscopy for diagnosis Therapy - antibiotics in the cirrhotic subset - vasopressors (terlipressin) - endoscopic banding treatment
What should you do in uncontrolled variceal bleeding?
Sengstaken tube
- tube inflated in the oesophagus to hold pressure on the bleeds
- balloon tamponade
TIPS
- transjugular intrahepatic portosystemic shunt
Surgical shunt/transection is TIPS fails
In general, what is the optimal management of an upper GI bleed?
Resuscitate
Risk assess
Time endoscopy
Drug therapy and transfusion
