Download AM disease - upper GI bleed

Definition
Epidemiology
50-150 per 100,000 per year (incidence)
10% mortality
Causes
chronic peptic ulcer
duodenal ulcer (40%)
gastric ulcer (20%)
acute peptic ulcer (30%)
Mallory-Weiss tear
gastric erosions
oesophageal/gastric varices, eg in portal hypertension
(malignancy is rare)
Risk factors
NSAIDs
Alcohol/smoking
Symptoms
Syncope/dizziness
Dyspepsia/epigastric pain
Weight loss
Key questions
Drug history
Alcohol history
Known/risk factors for liver disease
Signs
Hypotension (lack of, does not exclude significant bleed), tachyc, sweating
pallor (ie shock)
Post hypot
Stigmata alcohol/liver disease
Melaena on PR examination
Investigations
FBC (haemoglobin, may be normal until haemodilution occurs; leucocytosis and
thrombocythaemia are common)
INR, cross-match
U+Es (urea may be raised, due to protein load), LFTs/GGT, amylase
Key investigation
Endoscopy (identification of cause in >90% and permits treatment)
Specialist investigations
Treatment (first line)
(if significant)
Insert 2 large bore cannulae
Transfuse if systolic BP < 100 mm Hg or HR > 100 (use colloid initially)
give blood ASAP (aim for haemoglobin 12 g/dl)
GVP line (infuse, to maintain at +5 cm H20)
Urinary catheter
Nil by mouth, until endoscopy
PPI
Stop
NSAIDs, warfarin
Treatment (second line)
Sengstaken tube
Surgery
Admit?
Usually (some minor upper GI bleeds can go home)
Bed plan
Gastroenterology ward
± ITU?
Referral
Medical
Gastroenterology
± General surgery?
± ITU?
PAM
Alcohol counselling service, if appropriate
Score
Prognosis
10% mortality
25% rebleed, of these 1/3 mortality
Poor prognostic indicators include: old age, shock, rebleeding, varices
2° Prevention
Stop NSAID, alcohol
Don’t forget
Normal BP does not exclude significant bleed
Red flags
Local guideline (link)
National guideline (link)
Patient info (link)