Upper GI bleeds

Typical signs of an upper GI bleed:

• Haematemesis = the vomiting of blood. May be bright red if blood. However, appears ‘coffee ground’ if retained in the stomach for a short period due to the action of acid.

• Malaena = altered blood (black and tarry) passed PR. It implies bleeding proximal to the splenic flexure.

Causes:

1. Common:

• Gastric/duodenal ulcer (50%) (GU more likely to bleed/higher mortality than DU)

• Oesophageal varices (5-10%)

• Gastritis

• Mallory-Weiss tear (oesophageal tear due to vomiting)

• Portal hypertensive gastropathy

• Drugs:

• NSAIDs

• Steroids

• Thrombolytics

• Anticoagulants

2. Rarer:

• Nose bleeds (swallowed blood)

• Oesophageal/gastric malignancy

• Oesophagitis

• Haemobilia

• Peutz-Jegher’s syndrome (Benign small intestinal hamartomartous polyps occurring with dark freckles on lips, oral mucosa, face, palms and soles)

Assessment:

Swift, relevant history and examination

History:

• ‘Do you feel faint when you sit up?’ If yes, put up an IVI before continuing.

• Drugs (NSAIDs, steroids, anticoagulants)

• Alcohol abuse

• Previous GI bleed, peptic ulcer or its symptoms?

• Any other serious concomitant disease?

Examination:

• Vital signs (pulse, BP standing/lying, JVP, urine output)

• Signs of chronic liver disease?

• Jaundice (biliary colic + jaundice + Malaena suggests haemobilia)

Assess whether the patient is in shock:

• Cool and clammy to touch (especially nose, toes, fingers)

• Pulse >100bpm

• JVP <1cm H2O

• Systolic BP <100mmHg

Upper GI bleeds

Postural drop

Urine output <30mL/h

Immediate management if shocked:

• Protect airway

• Insert 2 large-bore ‘drips’

• Send bloods

• High flow O2

• Give IV colloid quickly then blood (ORh-ve until cross-match done). Aim for Hb of >10g/dl

• Correct clotting (Vitamin K, FFP)

• Set up CVP line to guide fluid replacement (aim for >5cm H20)

• Catheterize and monitor urine output

• Urgent diagnostic endoscopy – notify surgeons of all severe bleeds

Death from upper GI bleeds depends, chiefly, on 3 factors:

• Age

• Concomitant disease in the cardiopulmonary system

• Cause of bleeding

Indications for surgery:

• Severe bleeding

• Rockall score >6

• Re-bleeding

• Active bleeding during oesophago-gastro-duodenoscopy (OGD)

• Continuing bleeding after transfusion (if >60yrs, 6 units; if <60yrs 8 units)

Surgical Mx:

1. Varices:

• Oesophageal transaction with gun stapler re-anastomosis

• Transthoracic transoesophageal ligation

2. Gastric ulcer:

• Under-running

• Excision

• Partial gastrectomy