Upper GI Bleeds - SH2013

7/29/2019 Upper GI Bleeds - SH2013

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Upper GI Bleeds

SH


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Structure

Aetiology

Risk factors

Initial evaluation

Acute admissions

Scoring tools

Management overview

Specific treatment

Case studies


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Aetiology

Duodenal Ulcer

Gastric ulcer

Erosions

Oesophagitis

Mallory Weiss Tear

Oesophageal varices Neoplasms Zollinger Ellison syndrome


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Risk factors

RF for PUD: H-pylori

Alcohol use:

Acute MW tear

Chronic Oesophageal varices

Drugs

NSAIDs (Ibuprofen considered safest), Bisphosphonates

Antiplatelet/Anticoagulant use

(Iron supplements)

Recent abdominal surgery

Coagulopathy inherited vs aquired

AGE


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Initial evaluation

Symptoms

Haematemesis - active bleeding.

Coffee-ground vomitingslow/stopped.

Malaenafrequency?

Occult bleeds: anaemia fatigue, angina, SOB

Shock


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Vitals: hypotension, tachycardia - tennis rule.

General: Confusion? Pallor? Jaundice? Telangiectasia?

Abdo exam:

Organomegaly

Palpable masses

Peritonism/tenderness

Investigations

FBC anaemia, Hb, Hct, Plts, MCV

Baseline LFTs and U&Es (may show pre-renal AKI) Prothrombin time

Glucose

Serum amylase

Cross match 6 units


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Acute admissions

NBM. Closely monitor airway, clinical status, vital signs, cardiac rhythm

Two large bore IV lines (Green (14G) orGrey (16G))

Bolus infusions of isotonic crystalloid

Transfusion

pRBCsHb


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Scoring tools

Important as mortality rate 15%

NICE guidelines: ALL pts with UGIB need risk assessment.

First assessment: Blatchford scoreintervention.

Score > 6 needs interventionOffer endoscopy to unstable patients with severe acute upper

gastrointestinal bleeding immediately after resuscitation.

Offer endoscopy within 24 hours of admission to all other patients with

upper gastrointestinal bleeding.

After endoscopy: Rockall scoremortality

Score 8 high mortality.


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Rockall score

Components: - ABCDE (pre & post score. NICE post. SIGN both).


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Management overview

?

Endoscopy:

Variceal bleed

Non-variceal bleed


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Specific treatment

Non variceal bleeds

Endoscopic treatment:

1. Mechanical Rx: clips +/- adrenaline

2. Thermal coagulation + adrenaline

3. Fibrin or thrombin + adrenaline

PPIs: SRH on endoscopy (only for non-variceal bleeds).

IV omeprazole 80mg STAT, followed by infusion of 8mg/hourfor 72 hours.

Adrenaline not

monotherapy


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Specific treatment

Variceal bleeds

At presentation: Terlipressin and prophylactic

antibiotics (suspected).

Balloon tamponade to stabilise until endo.

Endoscopic treatment: band ligation

If not controlled transjugularintrahepatic portosystemic shunt.

Hepatic encephalopathy

Hepatic ischaemia


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Case studies

A. Gastric carcinoma

B. Gastric erosions

C. Oesophagitis

D. Oesophageal Ca

E. Oesophageal varices

F. MW tear

G. Peptic ulcer disease

H. Zollinger Ellison syndrome

32 year old woman who has been investigated for 1 year for

recurrent peptic ulceration, is admitted with haematemesis.Ranitidine failed to control symptoms, and she is taking

Omeprazole 40mg OD.

Endoscopy 2cm actively bleeding ulcer in duodenum.

CT 2cm mass in pancreas

73 year old man presents with several episodes of coffee-

ground vomiting. 5 month Hx of epigastric discomfort, nausea,anorexia (+ inability to eat normal sized meals) and weight loss.

FBC Hb 7.9/dl, MCV 76.6 fl, WCC 5.3 x 109/L, plts 333 x

109/L, INR 1.1

22 year old med student comes to ED after the annual college

beer race. After vomiting several times he notices bright redblood in the vomitus. He had only consumed 12 pints of beer

(as is the custom to complete the race).

FBC Hb 14.2 g/dl, MCV 85.6 fl, WCC 8.2 x 109/L, plts 450 x

109/L, INR 1.0


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Upper GI Bleeds - SH2013

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