Upper GI Bleeds Flashcards
What are the causes of an upper GI bleed?
Oesophageal - Malory Weiss Tear (A tear in the oesophageal mucosa that is not transmural), Oesophageal Varices, Oesophagitis, Oesophageal Malignancy
Gastric - Gastric Ulcer, Gastritis, Gastric Cancer
Duodenum - Duodenal Ulcer, Duodenitis
What will you find on a history of an upper GI bleed?
Symptoms
Blood in vomit - Coffee Ground (more likely peptic ulcer) or Fresh (more likely variceal)
Blood in stool - Normally Melaena (digested blood) but can be fresh in very large bleed
Shock – Fainting or postural dizziness
Epigastric Pain -Associated with Peptic Ulcers
Risk Factors: Alcohol Abuse Liver Disease Choric Renal Failure – Increases risk of peptic ulcer Increasing Age Drugs – NSAIDS, Anticoagulants
Specific Questions to ask:
Oesophageal Varices - Any signs/symptoms/history of liver disease, Alcoholism, Huge Bleed
Fictitious - Recent drinking of red liquid e.g. Red wine that may mimic blood
Peptic Ulcer - Recent stresses, History of indigestion or GORD, NSAID use,
Mallory Weiss Tear - Retching/vomiting, initially with no blood, recent binge drinking
Malignancy - Weight loss
Gastritis – Recent binge drinking
Calculate the Rockall Score
What will you look for on examination of a patient with a suspected upper GI bleed?
Examination findings: - What is the degree of anaemia/shock and are there signs of chronic liver disease End of the bed: Reduced skin turgidity - Hypovolaemia Pale – Hypovolaemia Low urine output – Hypovolaemia Hands: Palmar Erythema - chronic liver disease Duputrens contracture - chronic liver disease Leukonychia - chronic liver disease) Clubbing - chronic liver disease Increased capillary refill – Hypovolaemia Weak Peripheral pulses – Hypovolaemia Cold peripheries – Hypovolaemia Hypotension - Hypovolaemia Tachycardia - Hypovolaemia Face: Parotid enlargement - chronic liver disease Dry Mucous membranes - Hypovolaemia Chest: Spider Naevi - chronic liver disease Gynecomastia - chronic liver disease Loss of male body hair - chronic liver disease Abdomen: Hepatomegaly/Shrunken Liver - chronic liver disease Splenomegaly – Chronic Liver disease Caput medusa - chronic liver disease Atrophic Testes - chronic liver disease Legs: Weak Peripheral pulses – Hypovolaemia Cold peripheries – Hypovolaemia PR: May reveal evidence of lower GI bleed/melaena
What investigations will you order in acute upper GI bleeds management?
Bedside:
Urinary catheter with hourly urine output
ECG
Bloods:
FBC – To assess severity of bleed with Hb levels
U&E – A raised urea comparative to creatinine is classical of an upper GI bleed due to increased protein load which is then digested. May also see hyperkalaemia due to increased reabsorption ion the gut of K+ from digested blood
LFT - Looking for risk factors for varices
Clotting - They are bleeding, especially important in patients with signs of chronic liver disease and those on anticoagulants
Cross Match - They are bleeding
ABG – To assess severity of the bleed
Imaging:
CXR – May see perforated oesophagus, or pleural effusion as a result of an oesophageal tear
Upper GI Endoscopy – Arrange as soon as the patient is stable
High Risk Bleeds - Active bleeding, Adherent clot, Non-bleeding visible vessels
Low Risk Bleeds - Flat, Pigmented spot, Clean Base
Careful note of Posterior Duodenal ulcers as they re-bleed lot
What is the management of an upper GI bleed?
Indications for admission (Age>60, Still bleeding, Haemodynamic disturbance, Liver Disease, Major Co-morbidity)
Resuscitation:
A-E approach
Get IV Access (2 large bore cannulas (14-16))/Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Avoid Saline in Liver Failure
Assessment with AMPLE history and brief examination
Get help - Medical reg on call
Frequent Observations - Constant or 15 minutely
Transfusion with O- Blood or Cross matched blood if Hb<70
Transudes with Platelets if platelet count >50
Get advice from consultant/haematology on anticoagulation – Use FFP in patient with INR >1.5 and use PCC in actively bleeding patients taking warfarin. Factor VIIa can be used if either of these do not work. Stop any warfarin and talk to specialist about other blood thinners. Stop any NSAIDS in acute phase if possible.
Keep Nil by Mouth
Arrange urgent endoscopy - Immediately in severe bleeds, within 24 hours of all bleeds
Variceal Bleed:
Give Terlipressin (Give at presentation if high likelihood).
Give broad spectrum prophylactic antibiotics (Give at presentation if high likelihood)
Endoscopic Haemostasis with Banding (Oesophageal) or Injection Sclerotherapy (Gastric). Use Balloon tamponade for temporary salvage in uncontrollable bleed.
Give beta blocker post treatment as prophylaxis against further bleeds
Low risk ulcer:
No need for Endoscopic Haemostasis
Give Oral PPI (reduces risk of re-bleed)
Allow food/drink by mouth after 6 hours of being stable and test for H. Pylori
High risk ulcer:
Endoscopic Haemostasis with 2 of clips, adrenaline or cauterisation
Give Oral PPI (reduces risk of re-bleed)
Allow food/drink by mouth after 6 hours of being stable and test for H. Pylori
What scoring system is used for Upper GI bleeds? And what is it used for?
Scoring System: - Rockall Score (Predicts risk of re-bleeding and death) Age Shock Co-morbidity's Cause of the GI bleed Major stigmata of recent haemorrhage
