Home
Print Friendly, PDF & Email

Upper gastrointestinal bleeds (UGI) bleeds

 

 

Aetiology of upper GI (UGI) bleeds

  • Peptic ulcer disease –  oesophageal, gastric or duodenal ulcers
    • Prevalence 4% of the population
    • Due to H. pylori, NSAID use, alcohol, steroid use, Zollinger-Ellison syndrome (gastrin-secreting tumour causing multiple ulcers)
  • Oesophagitis and gastroduodenal erosions (15%)
    • Due to aspirin, other NSAIDs, steroids
  • Oesophageal varices
    • Due to portal hypertension, usually associated with chronic liver disease
  • Portal hypertensive gastropathy
  • Mallory-Weiss tears
    • Secondary to prolonged vomiting
  • Dieulafoy’s lesion
    • Tortuous arteriole usually upper part of lesser curve, bleeding occurs through a tiny defect.
  • GORD
  • Upper GI malignancy
  • Vascular malformations
  • Aorto-enteric fistula (commonest at approx 5 years post-surgery. Approx 2% risk)

 

History in upper GI (UGI) bleeds

  • History of presenting complaint
    • Haematemesis – can be bright red OR coffee-ground
    • Melaena – distinctive smell, tar-like
      • Volume of blood loss in either case
    • Dyspesia
    • Dizziness
    • Chest pain
    • Prolonged vomiting/retching
    • Constitutional symptoms
  • Past medical history
    • Previous GI bleed
    • Known PUD/varices
    • Malignancy
    • Liver disease
    • Known cardiovascular/respiratory disease (fitness to undergo sedation and/or intubation for endoscopy)
  • Medications
    • NSAIDs
    • Steroids
    • Anticoagulants
  • Allergies
  • Social history
    • Alcohol consumption

 

Video explaining Upper GI Bleeds

 

Examination of upper GI (UGI) bleeds

  • Signs of chronic liver disease
  • DRE for melaena
  • Signs of shock
    • Tachycardia, hypotension, altered conscious level, postural BP (often not appropriate in acute setting)
  • Encephalopathy

 

Initial management of acute upper GI (UGI) bleeds

– see http://www.nice.org.uk/guidance/cg141/chapter/1-recommendations for further details
  • Resuscitation
    • A – manage airway and consider need for intubation/airway adjunct or suctioning
    • B – give oxygen to maintain sats > 96%
    • C –
      • BP, HR
      • Large-bore IV access x 2
      • VBG to assess Hb, acidosis, lactate
      • Send lab bloods for FBC, U+Es, clotting, X-match (2-4 units usually)
      • IV fluid resuscitation (crystalloid is fine acutely)
    • D – AVPU, check glucose level
    • E – ?peritonitic abdomen
  • Imaging
    • Erect CXR to look for gas under diaphgragm
  • Catheter insertion for accurate fluid balance monitoring
  • Transfusion
    • Transfuse with x-matched (or O-neg or type-specific blood if very urgent) blood if haemodynamically unstable
    • Current guidelines suggest transfusing if Hb < 7 for patients with cirrhosis
    • If massive blood loss occurs then follow local protocols for transfusing platelets and clotting factors along with blood.
    • Give prothrombin concentrate complex to patients on warfarin who are actively bleeding
  • Proton-pump inhibitors
    • Current NICE guidance is NOT to give acid-suppression (PPIs, H2-RA) to patients with suspected non-variceal bleeds prior to endoscopy).
    • If evidence of recent haemorrhage then IV or oral PPI is given post-endoscopy
    • In practice however, this is still commonly given prior to endoscopy
  • Prokinetic
    • Metoclopramide 10mg IV can be given to empty the stomach contents to allow better views at endoscopy
  • Variceal bleeds
    • Treat as above
    • Give broad-spectrum antibiotics i.e. IV Tazocin 4.5g
    • Give IV Terlipressin 2g (unless peripheral vascular disease)
  • Endoscopy
    • Scoring system (see below)
    • Offer endoscopy to unstable patients with severe bleeding immediately after resuscitation
    • Offer endoscopy to all other patients within 24 hours
    • Management of non-variceal bleeding
      • Clips +/- adrenaline
      • Thermal coagulation with adrenaline
      • Fibrin/thrombin with adrenaline
    • Management of variceal bleeding
      • Band ligation for oesophageal varices
      • Injection of N-butyl-2-cyanoacrylate for gastric varices
      • Consider TIPSS procedure if the above methods do not control the bleeding

 

Further management of acute upper GI (UGI) bleeds

  • Sengstaken-Blakemore tube
    • A tube inserted into the stomach with gastric and oesophageal balloons – ONLY inflate the gastric balloon
    • Can only be used in intubated patients with varices
    • Used as a bridge for definitive therapy – usually either endoscopy or TIPSS
  • Surgical intervention
    • Perforated viscus

 

Scoring systems for upper GI (UGI) bleeds

  • Rockall
    • Prognosticates
    • Age, Shock, co-morbidities
      • Diagnosis and stigmata after endoscopy
    • Scores below 2 have a very low mortality
    • Scores 8 or higher have a mortality of 40%+

 

  • Blatchford-Glasgow
    • Risk stratify – predicts the need for hospital-based intervention
      • Urea, Hb, Systolic BP
      • Other: pulse, melaena, syncope, hepatic disease, cardiac failure
    • Use acutely but not as good as Rockall in predicting overall mortality
    • Score 0 = home
    • Score >0 = endoscopy
    • Score >5 (6 and up) = same day endoscopy

 

Click here for medical student OSCE and PACES questions about Upper GI bleed

Common Upper GI bleed exam questions for medical students, finals, OSCEs and MRCP PACES

 

Click here to download free teaching notes on Upper GI bleed: Upper GI Bleed

Perfect revision for medical students, finals, OSCEs and MRCP PACES