Transcript UPPER GASTROINTESTINAL BLEEDING

‘A Yellow Bleeder’
Kaushik Guha
Shirin Zaheri
Fariza Wan Jamaludin
Shebina Hakda
HISTORY - MR. Y:
 30y male, unemployed, known alcoholic liver disease
 PC - abdominal swelling and tenderness. *AMTS 7/10*
 HPC - Admitted 3.7.03 feeling unwell 3/7 with abdo pain &
rigidity, SOB, loss of appetite, nausea.
- 4.7.03 : spontaneous haematemesis at 2350, throughout night.
- Fresh, bright red blood with estimated loss: 3L.
- Darkening of stool and urine since then
- No itchiness
 SE - Weight stable, constipation, low mood & anxiety.
- No hx of previous haematemesis / NSAIDs / dyspepsia.
 PMH - Meningitis ‘91
- Cirrhosis due to ETOH few years ago.
 DH - NKDA
• Spironolactone
-KCl
• Insulin
-Chlordiazepoxide
• Pabrinex
-Multivitamin supplements
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FH - No alcohol dependence problem and liver diseases in the family
SH - ETOH hx:
• Started drinking 15 years ago
• Present consumption: 29 unit/day of mainly cider
• Last drink was the day before admission.
• Drinks by himself at home, rarely goes to the pub
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CAGE questionnaire
1. Cut down 
2. Annoyed 
3. Guilt
x
4. Eye opener 
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Started smoking at 14yrs. Now smokes 20-30 cigarettes /day.
Lives with father, he is very supportive.
Substance abuse - Nil
Forensic history - Nil
Alcohol dependence : 7/7
- Withdrawal symptoms: resting tremor, nausea
- Detox programme in Springfield March ‘03 but
unable to complete due to medical admission.
EXAMINATION - MR. Y:
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Pulse: 90/min, BP: 135/75, Temp: 36.7, Sats: 99%.
App : Polite, alert, not encephalopathic. No further haematemesis.
• Palmar erythema
- Xanthomas L palm.
• Leuconychia
- Bilateral yellow sclerae.
• Multiple spider naevi on chest
- Fine resting tremor
CVS: Pulse 90, regular, sinus rhythm.
• JVP not raised
• HS I + II + 0 , loud S II
RESP : Rate 28/min, decreased air entry bilateral lung bases.
ABDO: Distended, rigid, tense, mildly tender.
• Shifting dullness
• liver enlarged 2 cm below R costal edge
• no splenomegaly.
NEURO: Unremarkable
DDX
: Decompensated liver impairment secondary to ETOH
intoxication.
INVESTIGATIONS - MR Y:
1) FBC
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Hb
WBC
PLATELET
MCV
RBC
10.1 (13-17) 
6 (4-11)
71 (150-450) 
95 (80-97)
3.11 (4.5-6) 
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3) LFT
BILIRUBIN
ALBUMIN
ALT
GGT
ALP
66
27
18
148
85
(<17)

(35-48) 
(<52)

(<50)

(30-100)
2) BIOCHEMISTRY
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NA
K
CLHCO3
UREA2.1
CREATININE
123 (135-145)
4.2 (3.5-4.7)
96 (98-109)
20 (22-32)
(2.5-8.0)
43 (60-110)
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MANAGEMENT - MR. Y:
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Urgent endoscopy (OGD) 4.7.03 findings:
- fresh blood in oesphagus
- at least 6 varices with high risk stigmata, 1 varix spurting.
- fresh blood with clots in stomach, unable to exclude gastric
varices as fundus not visualised adequately.
Lower stomach and 1st & 2nd part of duodenum normal.
5 bands applied - bleeding stopped but blood reflux from
stomach.
F/U OGD 9.7.03 : 6 oesophageal varices
no red signs / no further bleeding / no banding ulceration
 F/U OGD 29.7.03: 4 oesophageal varices
 no red signs/ bleeding / ulceration
 F/U OGD due in 4 weeks.
EPIDEMIOLOGY:
 HAEMATEMESIS: vomiting of blood from a lesion
proximal to the distal duodenum.
 Accounts for 2500 hospital admissions each year in
UK.
 Annual incidence varies, 47-116/100,000.
 Higher in low socio-economic areas.
 Hospital mortality approximately 10%.
CAUSES OF UPPER GI BLEEDS:
OESOPHAGEAL VARICES-1:
 Increases in portal pressure cause development of
a portosystemic shunt
 Anamostoses with the systemic circulation are
commonly found in oesophagus, superior and inferior
epigastric veins (caput medusae), superior and
inferior rectal veins
 Causes can be divided between prehepatic,
hepatic and post hepatic
Commonest causes in West are alcoholic and viral
cirrhosis, worldwide schistosomiasis hepatic infection
OESOPHAGEAL VARICES -2:
OESOPHAGEAL VARICES-3:
GASTRIC ULCER:
MALLORY-WEISS TEAR:
MANAGEMENT OF UPPER GI BLEED:
 Resuscitate
 Assessment
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Airway
Breathing
Circulation
History
Examination
Investigations
INITIAL ASSESSMENT:
• Enquire about drug usage (esp. NSAIDS), EtOH,
retching, previous dysphagia and dyspepsia
• Examine for signs of chronic liver disease
• Check for melaena by PR
• Take blood for Hb, U&E, LFTs, Grp &
Save/Crossmatch and coagulation studies
INITIAL MANAGEMENT:
Suspected GI bleed
HIGH RISK
Acute severe
Hypotension
Haematemesis/melaena
High risk ‘stable’
Tachycardia > 100
Postural hypotension
Co-morbidity
Resuscitate
Inform
•GI Bleed reg (air call)
•Surgical reg
Resuscitate
Inform
•GI Bleed reg (air call)
Endoscopy
As soon as possible
Surgeon in attendance
GI bleed consultant informed
Endoscopy
Within 12 hours
LOW RISK
•Hb > 10g/dL
•<60 years and previously fit
•Coffee ground vomitus
•CVS stable
•Allow fluids
•Observe signs of continued
or rebleed
Endoscopy
Next routine list
Inform endoscopy by 9am
SECOND PHASE OF MANAGEMENT:
Varices
Bleeding continues
Bleeding stopped
High risk
Close monitoring
Measure CVP
Inform GI bleed team
•Banding
•Sclerotherapy
•Balloon tamponade
•Urine output
•Inform GI team
•Prevent encephalopathy
Low risk
Discuss mgmt
with GIB Reg
Early discharge
Plan for re-bleed
Options
Consultant endoscopy
Surgery
Radiological intervention
RISK OF RE-BLEEDING:
(Rockall Score)
AGE
SHOCK
COMORBIDITY
ENDOSCOPY
DIAGNOSIS
SCORE 0
SCORE 1
<60yrs
60-79yrs
 HR <100
 HR >100
 systolic
 systolic
>100mmHg
>100mmHg
 None
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None
Dark spot
None
Dark spot
MalloryWeiss
 No lesion
 All other dx
SCORE 2 SCORE 3
80yrs +
 HR >100
 systolic <100mmHg
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CCF
 RF
IHD
 LF
other
 malignancy
blood in upper GI tract
adherant clot
active spurting vessel
visible vessel within ulcer
Malignancy of upper GI
tract
Calculate Risk:
POST
ENDOSCOPY
SCORE
8+
7
6
5
4
3
0-2
RISK OF
DYING
(%)
40
23
12
11
8
2
0
RISK OF
RE-BLEED
(%)
37
37
27
25
15
12
6
• Re-bleeding in 50% in 10 days.
• Prognosis worse in those admitted for other reasons
and subsequently have an acute upper GI bleed, than
those admitted solely for bleeding.
• Recurrence thought to be 60-80% 2 years after initial
bleed.
LONG-TERM PREVENTION OF A
RE-BLEED:
 Banding: repeated at 2 weekly
intervals, follow-up endoscopy.
any increase in survival?
 Non selective beta-blockers (propanolol): HR at
rest,  portal pressure)
 risk of re-bleed
intolerance
 Isosorbide Mononitrate – releases nitric oxide 
vasodilatation.
systemic vasodilatation
renal function
 Surgery – TIPSS (Trans-jugular Intra-hepatic
Portal-System Shunt)
 In portal hypertension
of hepatic origin.
 Failed endoscopy.
 Bridge to subsequent
liver transplantation.
 When successful
the shunt prevents recurrent variceal bleeding.
Encephalopathy occurs in up to 25%.
Intimal proliferation – shunt dysfunction.
 Liver transplantation is the treatment of choice
in advanced liver disease.
 Portal hypertension and liver function restored.
 Survival at 1 yr is 80% and at 5 yrs is 60%.
REFERENCES:
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Bosch J et al. Prevention of Variceal Bleeding. Lancet 2003; 361:95254.
Rockall TA et al. Risk Assessment after acute upper GI haemorrhage.
Gut: 1996; 38:316-21.
Kumar P, Clark M. (Eds) Clinical Medicine. 5th Ed. 2002. WB Saunders.
Logan R, Harris A, Misiewicz J, Baron J. (Eds) ABC of the Upper
Gastrointestinal Tract. 2002. BMJ Books.
Ball C, Phillips R. (Eds) Evidence Based On Call: Acute Medicine
Pocketbook. 2002. Churchill Livingstone.