title: Acute Upper GI Bleeding author: "Callum Taylor" output: html_document: css: styles.css tags: notebook: 🌑-FFICM
Acute Upper GI Bleeding
Mortality in upper GI bleeds is high, 7% for all admissions, 30% in bleeding as inpatients. 1
Upper GI Bleed - Any point proximal to duodenojejunal flexure 1
Can be classified by pathophysiology and type of bleed. 1
In western countries Peptic Ulcer Disease is most common cause. Next most commen are oesophagogastric varices and oesophagitis. 1
There is NICE guidance for GI bleed management (NICE 141) 1
Stress Ulceration in critically ill? Can be up to 8.5% without prophylaxis. Major risk factors are invasive ventilation, coagulopothy. 1
Assessment
Take a clear history, usually theres haematemesis +/- malaena 1
May also be postural dizziness and collapse. 1
2/3 of patients who rebleed do so from same source. 1
NSAIDs can precipitate bleeding, so can anticoagulants/antiplatelets. 1
Comorbid disease like liver disease should be identified. 1
On examination:
- Tachycardia
- Postural Hypotension (after loss of 15% blood volume)
- Hypotension (after loss of 40% blood volume) 1
On initial tests: Routine bloods, plus some specific tests like screening for viral hepatitis. 1
Supportive Measures
- Supplemental Oxygen
- Tracheal Intubation (if ongoing bleeding and altered GCS/respiratory)
- Consider admission to critical care if refractory shock/resp failure/GCS failure
- Invasive BP monitoring
- CVP access
-
Wide bore cannulae 1
-
Major haemorrhage if needed 1
Target a Hb greater than 70 as the trial looking at 70 versus 90 found less mortality in 70. BUT remember these triggers were when looking at people who didn't have massive ongoing bleeding. 1
Give FFP if Prothrombin Time/APTT greater than 1.5 times normal. 1
Give cryoprecipitate if fibrinogen levels less than 1.5 despite giving FFP. 1
Give platelets if platelets less than 50 or if actively bleeding and on antiplatelet drugs. 1
Give warfarin a reversal. 1
Give DOAC it's reversal if there is one. 1
Drugs
PPIs - increase pH - that improves platelet functionm, inhibits fibrinolysis, slows gastric motility. 1
Terlipressin (synthetic Vasopressin) - slower acting than vasopressin and can be given as intermittent injections. It can slow portal blood flow (so can slow variceal bleeding). It reduces mortality in variceal bleeding. Can be stopped when haemostasis occurs, or after five days. 1
Somatostatin and octreotide are as effective as terlipressin. 1
Erythromycin is given as a prokinetic. It is associated with less need for second scope, less blood needed, and shorter hospital stay. But not recommended as standard. 1
TXA - Not recommended. 1
Abx - Improvve mortality 1
Risk Scoring
Rockall Score - Needs scope data, clinical data 1
Glasgow Blatchford Score - Doesn't need scope data, does need clinical and lab data 1
Procedures
OGD recommended either immediately after resus, or within 24hr otherwise 1
In scoping you can:
- Inject Adrenaline
-
Inject Thrombin and Fibrin 1
-
Place an endoscopic clip
- Use elctrocautery
- Use argon coagulator 1
For variceal you could ligate or sclerose vessels (through injections) 1
After Scope
PPI reduces rebleeding/need for further intervention/mortality 1
H pylori eradication if needed
Can restart low aspirin (with PPI) after haemostasis occurred 1 Only restart NSAIDs if needed 1 No evidence as to when to restart clopidogrel/DOAC 1
Variceal Bleeding Specifics
- Antibiotics and Terlipressin
You might need balloon tamponade to control bleeding, but that does come at high risk of rebleeding and complications 1
A transjugular intrahepatic portosystemic shunt may be needed to offload pressure from vessels. It is 90-100% effective at stopping oesophageal varices. 1
Balloon Tamponade with "Sengstaken Blakemore" or "minnessota" tube 1
You should intubate patients before placement to prevent aspiration. 1
Inflate gastric baloon up to 500ml, consider inflate oesophageal balloon with 45mmHg 1
Leave balloon in for up to 2 days 1