Examination
• Signs of chronic liver disease - Spider naevi - Ascites - Caput meduca - Rectal varices • melaena • Shock? - Cool, clammy, Cap refill >2s - ↓BP (<100) - ↓ urine output - Tachycardia - Confusion
Common Causes
- peptic ulcer disease (DU commonly)
- Acute erosions/ gastritis
- Mallory-Weiss tear
- Oesophageal varices
- Oesophagitis
- gastric or oesophageal CA
Rockall Score:
- Prediction of re-bleeding and mortality
- Initial score pre-endoscopy
- Age
- Shock: BP, pulse
- Comorbidities
• Final score post-endoscopy
- Final diagnosis + evidence of recent haemorrhage
- Active bleeding
- Visible vessel
- Adherent clot
• Initial score ≥3 or final >6 are indications for surgery
Oesophageal varices
• Portal HTN causes dilation of L. gastric and inferior oesophageal veins
Mx:
- Terlipressin IV
- 2 of: banding, sclerotherapy, adrenaline injection, coagulation
• TIPSS if bleeding can’t be stopped endoscopically
• Balloon tamponade with Sengstaken-Blakemore tube
- if haemorrhage worse or failure of endoscopic therapy
Transjuglar Intrahepatic Porto-Systemic Shunt
TIPSS
• artificial channel between hepatic vein and
portal vein → ↓ portal pressure.
• Tract through liver
parenchyma which expands using a balloon and maintained by placement of a stent.
• Used prophylactically or acutely if endoscopic therapy fails to control variceal bleeding
Terlipressin
Vasopressin analogue
Inhibits nitrous oxide release causing vasoconstriction and decreases portal venous blood flow
Prophylactic abx
Ciprofloxacin
Oesophageal ulcer mx
• Adrenaline injection and either:
- Thermal / laser coagulation
- Fibrin glue
- Endoclips
Afterr endoscopy
- Omeprazole IV + continuation PO
- Keep NBM for 24h → clear fluids → light diet @ 48h
- Daily bloods: FBC, U+E, LFT, clotting
- H. pylori testing and eradication
- Stop NSAIDs, steroids
Indications for Surgery
- Re-bleeding
• Bleeding despite transfusing of 6 units
• Uncontrollable bleeding at endoscopy
• Initial Rockall score ≥3, or final >6.
