Upper GI bleeding

Common causes;

• Peptic ulcers (40%)
• Mallory-Weiss tear (15%)
• Gastritis/gastric erosions (10%)
• Oesophagitis (10%)
• Oesophageal varices (7%)
• Malignancy
• Drugs – NSAIDs, aspirin, steroids, thrombolytics, anticoagulants

Examination

• Is the patient peripherally shut down – cool peripheries, increased cap refill time
• Reduced GCS?
• Poor urine output <o.5ml/kg/hr
• Tachycardia
• Hypotensive
• Postural drop
• Do a PR to look for melena
• Look for signs of liver disease
• Calculate the Rockall score

Rockall score

• Helps predict the risk of rebleeding and mortality after a GI bleed
• Initial score is based on age, presence of shock and any cormorbidities
• After endoscopy you can calculate a final Rockall score based on diagnosis and if there were any signs of recent haemorrhage on the endoscopy

Acute management

• Protect airway and give high flow oxygen
• Insert 2 wide bore cannulae and take blood for;
  • FBC
  • U&Es (increased urea out of proportion with creatine indicate a massive blood meal)
  • LFT
  • Clotting
  • Group and cross match (4-6units)
• Give IV crystalloids whilst waiting for blood to be crossmatched (if haemodynamically deteriorating give O negative blood)
• Insert urinary catheter and measure urine output
• Organise CXR, ECG, ABG
• Consider CVP line to monitor and guide fluid replacement
• Transfuse with cross matched blood until haemodynamically stable
• Correct clotting abnormalities – Vit K, FFP, platelets
• Arrange urgent endoscopy
• Inform surgeons of all severe bleeds on admission

Further management

• Give FFP if >4 units have been transfused
• Monitor pulse, BP, CVP and urine output hourly
• Transfuse to keep HB above 10g/dL (always keep 2 units of blood in reserve)
• Give omeprazole 40mg IV after endoscopy (reduces risk of further bleeding)

Endoscopy

• Should be done within 4hr of suspected variceal haemorrhage or within 24hr after admission when bleeding is ongoing
• Can identify site of bleeding, risk of further rebleeding and to administer treatment
• Treatment includes;
• Adrenaline, banding of varices, scleroptherapy and argon plasma coagulation

Rebleeding

• 40% of rebleeders die
• Identify high risk patients (Rockall score) and monitor closely
• Give IV omeprazole

Varices

• Develop in patients with cirrhosis once the portal pressure is >10mmHg (if 12mmHg bleeding may develop)
• Mortality of bleeding is 30-50% per episode

Causes of portal hypertension

• Prehepatic;
  • Portal vein thrombosis
  • Splenic vein thrombosis
• Intrahepative
  • Cirrhosis (80%)
  • Schistosomiasis
  • Sarcoidosis
  • Myeloproliferative disease
  • Congenital hepative fibrosis
• Post-hepatic;
  • Budd-Chiari syndrome
  • Right heart failure

Prophylaxis

• Primary
  • Without treatment 30% of cirrhotic patients with varices bleed, this is reducible to 15%
  • Propranolol
  • Endoscopic band ligation
• Secondary
  • After an initial bleed the risk of further rebleeding is 80% over the next 2 years
  • Give propranol and consider banding
  • Can also do TIPSS – transjugular intraheptatic portosystemic shunting

Management of acute variceal bleeding

• Resuscitate – don’t give normal saline (worsens ascites and increases Na in patients with a high body Na)
• Correct clotting abnormalities with VitK and FFP
• Start IVI terlipressin
• Give octreotide 50?g/hr IVI for 2-5 days
• Endoscopic banding or sclerotherapy  (when limited visualisation makes banding impossible)
• If massive bleed continues consider Sengstaken-Blakemore tube

Signs of a rebleed

• Rising pulse
• Falling JVP and decreased urine output
• Haematemesis or melaena
• Fall in BP (late)
• Reduced consciousness