Acute Upper Gastrointestinal Bleeds

Presentation

Symptoms

  • Haematemesis (most commonly)
  • Melaena.
  • Abdominal pain.
  • Features of chronic liver disease

Signs

  • Pallor
  • Hypotension and tachycardia
  • Reduced urine output
  • Melaena
  • Reduced Glasgow Coma Scale

History

  • Enquire regarding potential alcohol abuse
  • Past medical history that increases the risk of oesophageal varices
    • HIV
    • autoimmune liver disease
    • haemochromatosis
    • Wilson's disease
    • Other recognised causes of portal HTN, such as Budd-Chiari syndrome, myeloproliferative disorders, and sarcoidosis
  • Assess risk of H.Pylori infection if the patient has been travelling to an area where it is endemic

Differentials

  • Peptic ulcer disease
  • Oesophageal varices
  • Oesophagitis
  • Mallory-Weiss tear
  • Gastric varices

Vital Signs

Look for signs of shock:

  • Hypotension: SP <100
  • Tachycardia: HR >100 bpm
  • Insert a urinary catheter to ensure adequate volume replacement and begin a fluid balance chart

Examination

  • Assess signs of chronic liver disease
    • Jaundice
    • Encephalopathic flap
    • Spider naevi
    • Palmar erythema
    • Ascites
  • Perform a digital rectal examination to assess for melena which is associated with upper GI bleeds

Bedside tests

Risk assessments:

  • Blatchford score at first assessment
  • Rockall score after endoscopy

Laboratory investigations

  • Blood tests:FBC (low Hb), U&E, LFTs, cross-match and clotting
  • Assess for sepsis with a full septic screen - Culture ascites, blood, urine, sputum or do a CXR

Radiological investigations

Confirm diagnosis with endoscopy

  • For SEVERE gastrointestinal bleeding: Offer endoscopy to unstable patients immediately after resuscitation.
  • For all others: Offer endoscopy within 24 hours of admission

Management

Resuscitation

  • Gain large calibre IV access – give crytalloids until blood arrives if patient is tachycardic or hypotensive
  • Consider ventilation – if GCS is <8 ventilation may be required
  • Stop mediations that can provoke haemorrhage e.g NSAIDs, aspirin and reverse anticoagulants with advice from a haematologist
  • Antibiotics - use broad spectrum antibiotics to reduce mortality by reducing the rate of early rebleeding (e.g IV tazocin or oral ciprofloxacin)
  • Terlipressin prior to endoscopy (contra-indicated in patients with ischaemic heart disease) or peripheral vascular disease
  • Blood transfusion
    • Do not offer platelet transfusion to patients who are not actively bleeding
    • Offer platelet transfusion to patients who are actively bleeding and have a platelet count of < 50 x 109/litre
    • Consider FFP if INR > 1.5 than normal and there is active bleeding
    • Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
    • Do not offer recombinant factor VIIa except when all other methods have failed

Goals of resuscitation:

  • Maintain Hb at >8 g/dL
  • Systolic blood pressure >90 to 100 mmHg
  • Heart rate <100/min

Non-variceal bleeding (confirmed by endoscopy)

  • Do not use adrenaline as monotherapy!
  • Endoscopic treatment can be mechanical (e.g clips), thermal coagulation with adrenaline, fibrin or thrombin with adrenaline
  • Offer PPIs if bleeding is shown at endoscopy, not before
  • Consider a repeat endoscopy for patients at high risk of rebleeding and offer a repeat endoscopy for patients who did re-bleed

Variceal bleeding (confirmed by endoscopy)

  • Terlipressin given for 48 hours after endoscopy
  • Stop after haemostasis has been achieved or after 5 days

Oesophageal varices

  • First line treatment is Variceal Band ligation combined with a beta blocker
  • Consider TIPS if bleeding is not resolved

Gastric varices

  • First line treatment is endoscopic injection of N-butyl-2-cyanoacrylate
  • If this fails, consider TIPS

Prognosis

  • 70% chance of rebleeding after initial episode
  • Approximately one third of further bleeding episodes are fatal
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