UPPER G.

I BLEEDING

Background

Quite common
10% patient mortality
Variceal vs. non-variceal bleeding
Haematemesis and Malaena both indicate upper GI bleeding

Presentation

Haematemesis vomit blood (fresh red or coffee grounds)
Melaena PR altered blood (black, tarry stool)
o Occurs if blood remains in gut >14 hrs and haematin
o Can also occur in proximal colonic bleeds (so examine right colon as
well)
Haematochezia - Fresh blood PR
o Very brisk UGIB
o OR usually due to lower GI source
Symptoms of blood loss
o Syncope passing out
o Dyspnoea shortness of breath
o Angina chest pain (lack of blood supply to the heart)
o Shock
o Iron deficient anaemia

Triage and History taking

HISTORY - Ask about

PMH past GI bleeds, ulcers, liver disease, vomiting, weight loss
DH NSAIDs, aspirin, steroids, thrombolytics, anticoagulants
CO-MORBIDITIES CVR disease, hepatic or renal impairment, malignancy
SH Alcohol use

EXAMINATION Look for

Signs of chronic liver disease
PR check for melaena
Is the patient shocked?
Cool and clammy? Capillary re-fill time >2s
Urine output <1/2mL/kg/h
Tachycardic pulse >100bpm
Systolic BP <100mmHg
ROCKALL SCORE

OBS AND BLOODS

Pulse, Blood Pressure
Hb, Platelets, INR, Urea


ROCKALL SCORE



GLASGOW BLATCHFORD SCORE


What GBS score means
Chance of endoscopic
intervention.

0 discharge
1 1.5%
2-3 10%
4-10 20%
>10 30%

INITIAL MANAGEMENT

1. Protect airway, give high flow O2
2. IV access FBC, U&E, LFT, clotting, cross-match
a. FBC Look for Hb levels ( if <140g/L )
b. U&E - urea to creatine is indicative of massive blood meal
3. Give fluids whilst wait for crossmatching
a. If deteriating give group 0 Rh-ve blood
4. Urinary catheter
5. Transfuse
6. Correct clotting abnormalities
a. Vitamin K
b. FFP
c. Platelets
7. Monitor pulse, BP, CVP
8. MEDS
a. Omeprazole (PPI)
b. Terlipressin/octrectide (vasoactive)

TIMING OF ENDOSCOPY

NICE - <24HOURS
o Very early <6hrs, not proven to increase survival
o Must adequately resusciate first
Assess patient for fitness for endoscopy FIRST
Identifies bleeding site, estimate risk of re-bleed, aid-treatment
o RE-BLEED RISK
Arterial (80%)
Visible vessel (50%)
Adherent clot (30%)
o Risk of rebleed highest in the first 48hours
o Look for Haematemesis, pulse, BP, urine output
o TREAT
Repeat endoscopy
Radiology
Surgery
Check clotting


CAUSES OF UGIB:

Ulcers peptic
Mallory Weiss tear tear between stomach and esophagus (alcohol,
vomiting)
Erosions
Drugs
Duodentitis
Malignancy