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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)