Upper GI Bleeding

The most common cause of this is Peptic Ulcer Disease. Risk factors of this are H.pylori, NSAID use, and Smoking. Other causes to know are:

• Mallory-Weiss tear - due to rupture of the gastro-oesophageal junction after repetitive retching

• Oesophageal varices - due to portal hypertension

• Malignancy

Presentation:

The main ways in which GI bleeds present is with Haematemesis and/or Melaena.

Haematemesis - Frank blood or coffee-ground material. This only occurs in bleeds that occur from the mouth to the 2nd ½ of the duodenum as retroperistalsis only occurs from this point upwards.

Melaena - Black, tarry, greasy, foul-smelling stools. If a large bleed, patients will have signs of haemodynamic instability i.e. hypotension, tachycardia, oliguria, cold and clammy peripheries.

N.B. Tachycardia is the 1st sign seen in haemodynamic instability. Always need to check the patient's drug chart for b-blockers as it could mask any haemodynamic compromise during its early stages.

Patients may also present with signs that point towards an underlying pathology. For example:

• Epigastric pain and Dyspepsia/Indigestion - Peptic ulcer disease

• Jaundice, ascites, and alcohol hx - Oesophageal varices

Investigations and Management:

Urgent things to do in all patients is:

• A-E assessment

  • Main intervention to do here is Fluid Resuscitation, in which the patient should be put into Therapeutic Hypotension to avoid overload.

• Supplementary O2

• NBM

• IV access with 2 large-bore cannulas

  • May be difficult in the arms due to the patient being peripherally shut-down, therefore the femoral is usually used. Internal jugular isn’t used as it’s collapsed, therefore increasing the risk of hitting the carotid artery instead.

The bloods to do include:

• FBC, U&E, LFT, INR, G&S/Crossmatch

  • Urea will be raised as it's the product of protein breakdown and is excreted by the kidneys. Blood is like a “protein meal” in the gut, therefore urea is raised if digested.

Once the patient is stable, Endoscopy should be arranged.

Anticoagulants and NSAIDS to be stopped. If the patient is on Warfarin and INR is raised, stop the warfarin and give Cryoprecipitate first (as it works faster) + Vit K.

Scoring Systems:

• Blatchford score

• Rockall Score - Used to assess the % risk of re-bleeding and overall mortality. It can be used pre/post-endoscopy and takes into account risk factors, which includes:

  • Age

  • Haemodynamic instability

  • Co-morbidities

  • Cause of bleeding (e.g. Mallory-Weiss tear or Malignancy)

  • Endoscopic findings (e.g. clots, bleeding vessels)