Upper GI bleeding March 2018 | by EMauthor Enquire about, peptic ulceration, previous bleeds, liver disease, family history of bleeding, ulcerogenic medication/anticoagulants, alcohol and weight loss. Symptoms and signs •Coffee-ground vomit (dark brown, denatured blood in vomit) •Haematemesis (bright red or clotted blood in vomit) •Melaena (black, tarry, smelly stool containing digested blood) •Postural dizziness or fainting •Evidence of severe bleeding – defined as presence of shock with tachycardia (heart rate >100 beats/min), hypotension (systolic BP <100 mmHg) and clammy skin, or of postural hypotension in patient who is not clinically shocked •Features of precipitating disease, jaundice, stigmata of liver disease •Features of bleeding disorder (petechiae) •Buccal or facial telangiectasia Assessment of risk using use Glasgow Blatchford score (GBS) •If more than one of the following are present, patient is at high risk oHeart rate >100 beats/min and systolic BP <100 mmHg, or postural hypotension (fall ≥20 mmHg 3 min after standing) oRecent syncope oMelaena oHeart failure or liver disease oHaemoglobin (Hb) oUrea >6.5 mmol/L Emergency management •Bloods with clotting and group / screen. •Good IV access x 2 unless there is a strong suspicion of trivial bleed. Minimum 18G and avoid unnecessary use of ACF. Remember to check external jugulars. Consider early central access (e.g. Vascath) if the patient’s veins are poor and they are bleeding ++ •Alternatively, 14G angiocath (or even a 14G cannula in a thin patient) in a femoral vein works well. •If the patient is shocked; prescribe at least 2 units flying-squad while matched units are being prepared. There isn’t much value in fluids. Key point: the basics are essential. Issues arising from sick GI bleeders are rarely due to a lack of sophisticated monitoring or investigation--they are usually due to a lack of good IV access, and late transfusion. •Balloon tamponade should be considered as a temporary salvage procedure in uncontrolled variceal haemorrhage, best taught hands on •Proton pump inhibitors (PPIs)—are not recommended by SIGN but are almost always given in any case •Stop Aspirin, NSAIDs, and anticoagulants etc •Terlipressin should be given to patients with suspected variceal bleeding prior to endoscopy •Antibiotic therapy (e.g. tazocin and metronidazole)— should be commenced in all patients with an upper GI bleed and chronic liver disease. •Consider intubating for endoscopy if the patient is becoming obtunded and hosing blood. Don't worry about the bed state / where the endoscopy can be done etc Key point: there is no ambulatory care pathway for upper GI bleeds in BTUH. All require admission. |
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