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UPPER GI BLEED

UPPER GI BLEED. Kate Edwards FY1 Doctor. Definition. Any bleed from the GI tract proximal to ascending part of the duodenum (final ¼). A major cause of emergency admissions to hospitals. 5-10% mortality depending of level of bleeding and cause. Causes. Other.

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UPPER GI BLEED

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  1. UPPER GI BLEED Kate Edwards FY1 Doctor

  2. Definition • Any bleed from the GI tract proximal to ascending part of the duodenum (final ¼). • A major cause of emergency admissions to hospitals. • 5-10% mortality depending of level of bleeding and cause.

  3. Causes

  4. Other • Includes iatrogenic induced such as NSAID or poorly controlled anticoagulant use. • Rarely this also includes a Cushing ulcer due to over use of steroids. • Also cases were causes are not found.

  5. Hx of bleeding • Haematemisis: - fresh red blood in vomit or coffee ground. - Indicates bleeding from the oesophagus or stomach. -May be recurrent minor episodes; however one major episode my compromise airway. • Malaena: - Offensive black tarry stools. - Indicates bleeding from after the pyloric sphincter. - May also indicate Lower GI bleed. - Ensure patient is not on iron tablets.

  6. Associated symptoms • Anaemia if chronic bleeding • Collapse/shock if major bleed • Weakness/dizziness • Palpitations • Sweating • Weakness • Hx of dypepsia • Hx of epigastric pain • Hx of NSAID use • Hx of alcohol abuse

  7. Examination • ONLY if patient is haemodynamically stable, otherwise treat first then examine for cause when stable. • Hands – look for liver signs such as liver flap, and palmaerythema. • Pulse and BP - to asses patients haemodynamic status, early warning is rise in HR, later is drop in BP. • Face – for anaemia and jaundice in sclera. • Chest/arms – spider neva. • Abdo – Ascities, caput medusae, epigastric tenderness, feel for aortic aneurysm/hepatomegaly. • PR – feel for haemorrhoids, stool in the rectum, look for malaena.

  8. Initial Management in major bleed • ASSESS ABC. • Airway – Ensure airway is secure, use suction to remove blood/vomit, if compromised insert airway adjunct. • Breathing – High flow oxygen 15lt at 100%, check sats. • C – Insert two large bore cannulas, restore circulating volume using colloids/O negative blood, then cross matched 4-8 units (takes approx 45-60 mins). • Bloods – FBC, U&E, Glucose, LFTS, Coag screen, G&S. • Catherterise – monitor urine output (aim for >30ml/hr) • NG tube after resus to assess severity. • If clotting deranged the use vit K/FFP.

  9. Establish Diagnosis • Via OGD endoscopy. • Only to be done once patient is haemodynamically stable. • To be under taken within 24hrs of admission, in severe upper GI bleed should be within 4 hrs. • Advantages of endoscopy: - Assess severity of bleeding. - Identify cause of bleeding. - Identify whether patient is suitable for surgery. - Perform basic management of cause. - Test for H.pylori.

  10. Endoscopic Diagnosis PUD Oesophageal Varices Mallory-Weiss Tear

  11. Oesophageal Varices • Over distended veins caused by the formation of shunts due to portal hypertension. • Shunt varicies are common in the oesophagus, superfical veins (caput medusae) and rectum (hemarroids). • Portal hypertension is caused by chronic liver disease/cirrohsis (usually due to alcohol abuse) • Enlargement of the liver causes increased pressure within the portal system leading to shunt formation.

  12. Specific Management of varices • Terlipressin given at presentation to reduce portal pressure. • Prophylactic antibiotic therapy. • Balloon tamponade should be considered as a temporary salvage treatment for uncontrolled variceal haemorrhage. • Endoscopy: • Band Ligation • Injection of  N-butyl-2-cyanoacrylate • If fail then TransjugularIntrahepaticPortosystemic Shunt (TIPS) formation.

  13. Peptic Ulcer Disease • A break in the continuity of the epithelium in the stomach or duodenum. • Causes include: H. Pylori infection, long term NSAID/Steroid use, smoking/alcohol/stress and Zollinger-Ellison syndrome. • Clinical Features include – dyspepsia, waterbrash, epigastric tenderness, related with eating. • H. Pylori infection is the commonest cause as it is found in 90% of patients with PUD, can be tested for via breath test or biopsy during OGD. • Complications include haemorrhage, perforation or pyloric stenosis.

  14. Specific Management of PUD • Reduce risk factors. • Initially Antacids, PPI, H2 receptor antagonist. • Eradication of H. Pylori via triple therapy for 1 week: • PPI e.g. Omeprazole/lansoprozle • Amoxicillin • Clarithromycin • Endoscopy: • Injection of adrenaline around ulcer • Electrocoagulation • Laser Coagulopathy • Surgery may be required to over sew ulcer.

  15. Mallory-Weiss Tear • Occurs at Gastro-oesophageal junction. • Caused by excessive and prolonged vomiting/retching often following large bouts of alcohol consumption. • Vomit is initially normal then bright red. • Most stop spontaneously however endoscopic clipping or surgery may be required.

  16. Risk of Re-Bleed: ROCKALL Score Score of <3 is minor, >8 is major. Mortality if approx: 3 pts – 10%, 5pts – 40%, 7 pts – 50%

  17. Mild to Moderate • Admit to general medical ward. • Observe for continued bleeding or re-bleeding. • Endoscopy within 24 hrs and repeat in 6 weeks. • Discharge when stable/no evidence of rebleed.

  18. Severe • Admit to HDU. • Observe closely for continuation of bleed/rebleed: • HR/BP • UO • CVP • Restore blood volume with IV fluids. • Keep patient fasted. • Emergency endoscopy.

  19. Case 1 • 65 yr old man admitted with coffee ground vomit. • C/O mild weakness/feeling faint for 3/7 • Also notices possible dark colour to stools. • H/O dypepsia. • Smoker and drug hx takes NSAIDs for joint pain. • O/E MEWS 0, tender epigastric region, pale sclera. Initial Diagnosis? Investigations? Management?

  20. Case 1 • Likely diagnosis PUD. • Must assess ABC and ensure patient is stable. • Investigations: • Erect CXR and AXR to exclude perforation. • Bloods – FBC, U&Es, LFTs, coag screen, G&S. • Management: • IV PPI and omit NSAIDs • Endoscopy within 24hrs including possible treatment. • If H. Pylori positive then triple therapy.

  21. Case 2 • 48 yr old man admitted with sever haematemesis. • Patient is tachy with drop in BP. • Pt has yellow sclera and spider neva on torso. • PMHx of liver failure, sever alcohol abuse. Likely Diagnosis? Immediate management?

  22. Case 2 • Likely to be varices bleed. • Initial management is to assess via ABC. • Ensure airway maintained. • Give O2 and monitor sats. • IV access with colloid/o negative blood until cross match (4-6units) • Give terilpressin and emergency endoscopy. • If airway compromised then balloon tamponade. • Insert Catheter and NG. • Admit to HDU. • Endoscopy finds: Varices and major haemorrhage in gi tract. Rockall Score?

  23. Case 2

  24. Case 2 • Rockall Score: • Age: 48 - 0 • Shock: Hypotensive - 2 • Co-morbidity: Liver failure – 3 • Diagnosis: Varices – 2 • Major SRH: Blood in Gi tract – 2 • Total = 9/11 • Severe bleed, mortality rate of 50% and high risk of re-bleed. • Needs HDU input and close monitoring.

  25. Any Questions?

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