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gitbleeding_upper

upper GIT bleeding

Introduction

  • upper GIT bleeding is a potentially life threatening condition and may present as either:

Aetiology

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, of Hb is low then exclude from this category and treat as per below
  • assess for possible referral to GP to arrange gastroscopy as an outpatient (see risk assessment below)

upper GIT bleed in the patient with cirrhosis

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
      • 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

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
gitbleeding_upper.txt · Last modified: 2020/06/22 22:11 by gary1