Transcript 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.
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CAUSES
Mallory-Weiss
Syndrome
2%
Gastric Ca
2%
Other
10%
Oesophagitis
11%
Oesophageal Varicies
45%
Gastric Erosion
13%
PUD
17%
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.
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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.
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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
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EXAMINATION
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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 palma erythema.
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
INITIAL MANAGEMENT IN MAJOR BLEED
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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.
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.
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ENDOSCOPIC DIAGNOSIS
PUD
Oesophageal
Varices
Mallory-Weiss
Tear
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.
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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:
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Band Ligation
 Injection of N-butyl-2-cyanoacrylate
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If fail then Transjugular Intrahepatic
Portosystemic Shunt (TIPS) formation.
PEPTIC ULCER DISEASE
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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 ZollingerEllison 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.
SPECIFIC MANAGEMENT OF PUD
Reduce risk factors.
 Initially Antacids, PPI, H2 receptor antagonist.
 Eradication of H. Pylori via triple therapy for 1
week:
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PPI e.g. Omeprazole/lansoprozle
 Amoxicillin
 Clarithromycin
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Endoscopy:
Injection of adrenaline around ulcer
 Electrocoagulation
 Laser Coagulopathy
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Surgery may be required to over sew ulcer.
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.
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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%
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.
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SEVERE
Admit to HDU.
 Observe closely for continuation of bleed/rebleed:
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HR/BP
 UO
 CVP
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Restore blood volume with IV fluids.
 Keep patient fasted.
 Emergency endoscopy.
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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.
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Initial Diagnosis?
Investigations?
Management?
CASE 1
Likely diagnosis PUD.
 Must assess ABC and ensure patient is stable.
 Investigations:
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Erect CXR and AXR to exclude perforation.
 Bloods – FBC, U&Es, LFTs, coag screen, G&S.
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Management:
IV PPI and omit NSAIDs
 Endoscopy within 24hrs including possible
treatment.
 If H. Pylori positive then triple therapy.
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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.
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Likely Diagnosis?
Immediate management?
CASE 2
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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?
CASE 2
CASE 2
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Rockall Score:
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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.
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ANY QUESTIONS?