gitbleeding_upper
Table of Contents
upper GIT bleeding
see also:
Introduction
- upper GIT bleeding is a potentially life threatening condition and may present as either:
- coffee ground vomits
- frank haematemesis
- melaena
- chronic or subacute iron deficiency anaemia
- undifferentiated presentation but with raised serum urea
Aetiology
- 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
- penetrating duodenal ulcer
Severity Scoring
Rockall score pre-endoscopy
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:
- Score 0 = 0.2% mortality prior to endoscopy
- Score 1 = 2.4% mortality prior to endoscopy
- Score 2 = 5.6% mortality prior to endoscopy
- Score 3 = 11% mortality prior to endoscopy
- Score 4 = 25% mortality prior to endoscopy
- Score 5 = 40% mortality prior to endoscopy
- Score 6 = 49% mortality prior to endoscopy
- Score 7 = 50% mortality prior to endoscopy
Low Risk Criteria of Glasgow-Blatchford bleeding score
- urea <6.5 mmol/L
- Haemoglobin >130 g/L (men) or >120 g/L (women)
- systolic BP > 110 mmHg
- pulse <100 bpm
- absence of melaena, syncope, cardiac failure or liver disease
Mx in ED
the extremely low risk patient
- 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
subacute or chronic iron deficiency anaemia without active bleeding
- 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
the low risk acute bleed
- 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)
upper GIT bleed in the patient with cirrhosis
- this is most likely due to oesophageal varices - GO TO oesophageal varices for Mx.
most of the rest
- 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
Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage
gitbleeding_upper.txt · Last modified: 2021/11/13 12:37 by gary1