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Flashcards in Upper GI Bleeds Deck (6):
1

What are the causes of an upper GI bleed?

Oesophageal - Malory Weiss Tear (A tear in the oesophageal mucosa that is not transmural), Oesophageal Varices, Oesophagitis, Oesophageal Malignancy
Gastric - Gastric Ulcer, Gastritis, Gastric Cancer
Duodenum - Duodenal Ulcer, Duodenitis

2

What will you find on a history of an upper GI bleed?

Symptoms
Blood in vomit - Coffee Ground (more likely peptic ulcer) or Fresh (more likely variceal)
Blood in stool - Normally Melaena (digested blood) but can be fresh in very large bleed
Shock – Fainting or postural dizziness
Epigastric Pain -Associated with Peptic Ulcers

Risk Factors:
Alcohol Abuse
Liver Disease
Choric Renal Failure – Increases risk of peptic ulcer
Increasing Age
Drugs – NSAIDS, Anticoagulants

Specific Questions to ask:
Oesophageal Varices - Any signs/symptoms/history of liver disease, Alcoholism, Huge Bleed
Fictitious - Recent drinking of red liquid e.g. Red wine that may mimic blood
Peptic Ulcer - Recent stresses, History of indigestion or GORD, NSAID use,
Mallory Weiss Tear - Retching/vomiting, initially with no blood, recent binge drinking
Malignancy - Weight loss
Gastritis – Recent binge drinking
Calculate the Rockall Score

3

What will you look for on examination of a patient with a suspected upper GI bleed?

Examination findings: - What is the degree of anaemia/shock and are there signs of chronic liver disease
End of the bed:
Reduced skin turgidity - Hypovolaemia
Pale – Hypovolaemia
Low urine output – Hypovolaemia
Hands:
Palmar Erythema - chronic liver disease
Duputrens contracture - chronic liver disease
Leukonychia - chronic liver disease)
Clubbing - chronic liver disease
Increased capillary refill – Hypovolaemia
Weak Peripheral pulses – Hypovolaemia
Cold peripheries – Hypovolaemia
Hypotension - Hypovolaemia
Tachycardia - Hypovolaemia
Face:
Parotid enlargement - chronic liver disease
Dry Mucous membranes - Hypovolaemia
Chest:
Spider Naevi - chronic liver disease
Gynecomastia - chronic liver disease
Loss of male body hair - chronic liver disease
Abdomen:
Hepatomegaly/Shrunken Liver - chronic liver disease
Splenomegaly – Chronic Liver disease
Caput medusa - chronic liver disease
Atrophic Testes - chronic liver disease
Legs:
Weak Peripheral pulses – Hypovolaemia
Cold peripheries – Hypovolaemia
PR:
May reveal evidence of lower GI bleed/melaena

4

What investigations will you order in acute upper GI bleeds management?

Bedside:
Urinary catheter with hourly urine output
ECG

Bloods:
FBC – To assess severity of bleed with Hb levels
U&E – A raised urea comparative to creatinine is classical of an upper GI bleed due to increased protein load which is then digested. May also see hyperkalaemia due to increased reabsorption ion the gut of K+ from digested blood
LFT - Looking for risk factors for varices
Clotting - They are bleeding, especially important in patients with signs of chronic liver disease and those on anticoagulants
Cross Match - They are bleeding
ABG – To assess severity of the bleed


Imaging:
CXR – May see perforated oesophagus, or pleural effusion as a result of an oesophageal tear
Upper GI Endoscopy – Arrange as soon as the patient is stable
High Risk Bleeds - Active bleeding, Adherent clot, Non-bleeding visible vessels
Low Risk Bleeds - Flat, Pigmented spot, Clean Base
Careful note of Posterior Duodenal ulcers as they re-bleed lot

5

What is the management of an upper GI bleed?

Indications for admission (Age>60, Still bleeding, Haemodynamic disturbance, Liver Disease, Major Co-morbidity)

Resuscitation:
A-E approach
Get IV Access (2 large bore cannulas (14-16))/Give O2 to maintain sats of 94+ /Attach 12 lead ECG
Avoid Saline in Liver Failure
Assessment with AMPLE history and brief examination
Get help - Medical reg on call
Frequent Observations - Constant or 15 minutely
Transfusion with O- Blood or Cross matched blood if Hb<70
Transudes with Platelets if platelet count >50
Get advice from consultant/haematology on anticoagulation – Use FFP in patient with INR >1.5 and use PCC in actively bleeding patients taking warfarin. Factor VIIa can be used if either of these do not work. Stop any warfarin and talk to specialist about other blood thinners. Stop any NSAIDS in acute phase if possible.
Keep Nil by Mouth
Arrange urgent endoscopy - Immediately in severe bleeds, within 24 hours of all bleeds

Variceal Bleed:
Give Terlipressin (Give at presentation if high likelihood).
Give broad spectrum prophylactic antibiotics (Give at presentation if high likelihood)
Endoscopic Haemostasis with Banding (Oesophageal) or Injection Sclerotherapy (Gastric). Use Balloon tamponade for temporary salvage in uncontrollable bleed.
Give beta blocker post treatment as prophylaxis against further bleeds

Low risk ulcer:
No need for Endoscopic Haemostasis
Give Oral PPI (reduces risk of re-bleed)
Allow food/drink by mouth after 6 hours of being stable and test for H. Pylori

High risk ulcer:
Endoscopic Haemostasis with 2 of clips, adrenaline or cauterisation
Give Oral PPI (reduces risk of re-bleed)
Allow food/drink by mouth after 6 hours of being stable and test for H. Pylori

6

What scoring system is used for Upper GI bleeds? And what is it used for?

Scoring System: - Rockall Score (Predicts risk of re-bleeding and death)
Age
Shock
Co-morbidity's
Cause of the GI bleed
Major stigmata of recent haemorrhage