FN: Upper GI bleed

Question 1

History

Answer 1

Previous bleeds
Dyspepsia, known ulcers
Liver disease or oesophageal varices
Dysphagia, wt. loss
Drugs and ETOH
Co-morbidities

Question 2

O/E

Answer 2

Signs of Chronic liver disease
PR: melaena
Shock?
•	Cool, clammy, CRT >2s
•	Reduced BP (<30ml/h)
•	Reduced GCS

Question 3

Common causes

Answer 3

PUD: 40% (DU commonly)
Acute erosions/gastritis:20%
Mallory-Weiss ear:10%
Varices: 5%
Oesophagitis:5%
Ca stomach/oesophagus:<3%

Question 4

Oesophageal Varices →

Answer 4

• Portal HTN → dilated veins @ sites of proto-systemic anastomosis: L.gastric and inferior oesophageal veins
• 30-50% with portal HTN will bleed from varices
• Overall mortality 25%: increased with severity of liver disease

Question 5

Causes of Portal Hypertension:

Answer 5

PRE-hepatic
Hepatic
Post-hepatic

Question 6

Pre-hepatic

Answer 6

Portal vein thrombosis

Hepatic: cirrhosis (80% in UK), schisto (commonest worldwide), sarcoidosis

Question 7

Hepatic

Answer 7

Cirrhosis (80% in UK), schisto (commonest worldwide), sarcoidosis

Question 8

Post-hepatic:

Answer 8

Budd-chiari, RHF, constrict preicarditis

Question 9

Management of blled

Answer 9

1. Resuscitation
2. Give blood if remain shocked
3. Variceal bleed
4. Maintenance
5. Urgent Endoscopy
   a. haemostasis of vessel or ulcer
   b. Variceal bleeding
6. After endoscopy

Question 10

Resuscitation

Answer 10

• Head-down
• 100% O2, protect airway
• 2 x 14G cannulae + IV crystalloid infusion up to 1L
• Bloods:
→FBC, U + E (increase urea), LFTs, clotting, x-match 6u, ABG, glucose

Question 11

Blood if remains shocked

Answer 11

• Terlipressin IV (splanchnic vasopressor)

* Prophylactic ABX: e.g. ciprofloxacin 1g/24h

Question 12

Variceal bleed

Answer 12

• Terlipressin IV (splanchnic vasopressor)

* Prophylactic ABX: e.g. ciprofloxacin 1g/24h

Question 13

Maintenance

Answer 13

• Crystalloid IVI, transfuse if necessary (keep Hb >10)
• Catheter + consider CVP (aim for >5cm H2o)
• Correct coagulopathy: vit K, FFP, platelets
• Thamine if EtOH
• Notify surgeons of severe bleeds

Question 14

Haemostasis of vessel or ulcer:

Answer 14

• Adrenaline injection
• Thermal/laser coagulation
• Fibrin glue
• Endoclips

Question 15

Variceal bleeding:

Answer 15

• 2 of: banding, sclerotherapy, adrenaline, coagulation
• Balloon tamponade with Sengstaken – Blakemore tube
• TIPSS

Question 16

After endoscopy

Answer 16

• Omeprazole IV + continuation PO (reduces re-bleeding))
• Keep NBM for 24h → clear fluids → light diet @ 48h
• Daily bloods: FBC, U+E, LFT, clotting
• H.[ylori testing and eradication
• Stop NSAIDS, steroids etc.

Question 17

Indications for surgery

Answer 17

•	Re-bleeding
•	Bleeding despite transfusing 6u
•	Uncontrollabel bleeding at endoscopy
•	Initial Rockall score >3 or final >6
Open stomach find bleeder and underrun vessel.