upper GIT bleeding

Introduction

peptic ulcer disease (PUD) - up to 50% of cases
oesophagitis - up to a third of cases
gastritis or duodenitis - 10-20% of cases
oesophageal varices - 5-12% of cases - mainly in those with liver disease and portal hypertension
Mallory-Weiss tear after vigorous vomiting
tumour in 2-5% eg. stomach cancer, oesophageal cancer
angiodysplasia in 2-3%
aorto-enteric or aorto-oesophageal fistula in less than 1% but presents with lethal haemorrhage although a third have an earlier resolving mild sentinel bleed
- button battery ingestions in children with delayed removal
- thoracic aortic aneurysms account for 90% of aorto-oesophageal fistulae
- oesophageal cancer
- penetrating duodenal ulcer
post-bariatric surgery
- eg. Roux-en-Y gastric bypass surgery with antecolic roux limb
  - marginal ulcer at the gastrojejunal anastomosis
    - this is the most common cause of both early and late post-RYGB bleeding. The jejunal mucosa becomes chronically exposed to gastric acid; Higher risk in smokers;
  - staple line bleeding:
    - common in the immediate postoperative period, typically caused by incomplete haemostasis along the anastomotic lines of the pouch, jejunojejunostomy, or the bypassed gastric remnant
  - gastric remnant or duodenal ulcers:
    - the excluded stomach and duodenum are still exposed to gastric juices and may ulcerate and bleed.
    - esp. if untreated H. pylori infection or use of NSAIDs or aspirin

criteria	Score 0	Score 1	Score 2	Score 3
age	< 60yrs	60-79yrs	>= 80yrs
shock	no shock	HR >= 100 and SBP >= 100	SBP < 100
comorbidities	no major		any major except those that score 3	renal failure, liver failure or disseminated malignancy

Interpretation of total sum Rockall score:

just a small amount of blood at the end of a vigorous vomiting episode (most M-W tears are benign)
supportive care and observation may be all that is needed unless there is ongoing bleeding evident

treat the iron deficiency anaemia on its merits (may need blood transfusion, iron infusion or supplemental oral iron)
if there is no active bleeding, refer back to GP to arrange gastroscopy and colonoscopy
- if the patient has co-morbidities that preclude safe endoscopies in the day procedure centers, then referral to the hospital endoscopy service will be required

small amount of coffee ground vomit with no high risk features such as either of:
- tachycardia (eg. > 100 for adults)
- hypotension (eg., systolic < 110mmHg for adults)
- syncope
- PH liver disease
- PH cardiac failure
- melaena - a PR exam is usually required to exclude this
FBE, U&E, Xmatch, LFTs, lipase, coagulation profile
- if urea is raised, or Hb is low then exclude from this category and treat as per below
commence oral proton pump inhibitors (PPIs)
assess for possible referral to GP to arrange gastroscopy as an outpatient (see risk assessment below)

this is most likely due to oesophageal varices - GO TO oesophageal varices for Mx.

assuming patient does not have an Advanced Care Directive that indicates otherwise, have a low threshold for aggressive early resuscitative Rx as significant bleeds can be occult initially
FBE, U&E, LFTs, lipase, CRP, Xmatch, coagulation profile
if significant haemorrhage or patient is in shock:
- large bore IV access (at least 18G in a large vein) x 2
- resuscitate with fluid replacement (preferably with blood)
- may need to activate the hospital's massive blood transfusion procedure (MTP)
- may need FFP if INR > 1.5
- may need platelets if platelet count < 50 x 10⁹/L
- start proton pump inhibitors (PPIs) ASAP
  - eg. iv bolus omeprazole 80mg in 100mL NSaline followed by infusion at 8mg/hr for 72hrs
- early referral to gastroenterology as may need endoscopy within 24hrs
  - early endoscopy aids diagnosis, finds the bleeding source in 90%, may allow Rx such as adrenaline injection, sclerotherapy, etc, and decreases hospital length of stay.
  - may need surgery or angiography if endoscopy fails