Upper GI bleeding

Upper GI bleeding

1. Haematemesis: vomiting of blood. Bright red or look like ground coffee. Malaena: black motion, blood smell.

2. Causes

   • Common: Mallory-Weiss tear, oesophagitis, oesophageal varices, peptic ulcers, gastritis/gastric erosions, duodenitis, malignancy, drugs (NSAIDs, aspirin, steroids, thrombolytics, anticoagulants).
   • Rare: bleeding disorders, portal hypertensive gastropathy, aorta-enteric fistula, angiodysplasia, haemobilia, dieulafoy lesion, meckel's diverticulum, Peutz-Jegher's syndrome, Osler-Weber-Rendu syndrome.
   • Risk factors: previous GI bleeds, dyspepsia, known ulcers, known liver disease or oesophageal varices, dysphagia, vomiting.

3. Features

   • Signs: signs of chronic liver disease, PR to check for melaena, peripherally shut down (cool and clammy), cap refill >2secs, reduced GCS, signs of encephalopathy, poor urine output (<0.5ml/kg/hr), tachycardic (pulse >100), hypotensive (sys BP <100mmHg), postural drop in BP (>20mmHg sys). Calculate Rockall risk score.
   • Rockall risk score: Pre-endoscopy: Age: <60yo =0, 60-79yo =1, 80+ =2. Shock- sys BP & HR: BP>100 & HR<100 =0, BP>100 & HR>100 =1, BP<100 =2. Co-morbidity: Nil major =0, cardiac failure/IHD =1, renal/liver failure =2, mets =3. Post-endoscopy: Diagnosis: Mallory-Weiss tear/no lesion/no recent bleeding =0, all other diagnoses =1, Upper GI malignancy =2. Signs of recent haemorrhage: none/dark red spot =0, blood in upper GI tract, adherent clot, visible vessel =2.
     • Predict risk of rebleeding and mortality. Initial score- pre-endoscopy, final score- post-endoscopy. Scored from 0-8+. Initial score of 6 indicates need for surgery (48.9% risk of mortality).

4. Management

   • Acute: protect airway, give high flow O2. Insert 2 large (14-16G) IV cannulae and take blood for FBC (haemodilution may not occur straight away), U&E (urea out of proportion to creatinine indicates blood meal), LFT, clotting and cross-match 4-6 units. Give IV crystalloid to restore intravascular volume whilst awaiting cross-match, (if dire ie haemodynamically deteriorating despite fluid resuc give O Rh-ve blood. Insert urinary catheter and measure hourly output. CXR, ECG, ABG. CVP line to guide replacement. Transfuse blood until stable. Urgent endoscopy. Inform surgeons of all severe bleeds on admission.