UPPER GASTROINTESTINAL BLEEDING

RESUSCITATION

• Severe bleeding needs the early involvement of both the gastroenterologist and surgeon
• Usually due to variceal bleeding, peptic ulcer and occasionally aorto-enteric fistula

AIRWAY

• Intubate if massive bleeding, obtundation, unable to maintain airway or anticipated need for Sengstaken-Blakemore tube

CIRCULATION

• 2 x 16G IV access in each limb
• Urgent Crossmatch 6 Units (Consider O -ve or Type Specific blood initially if severely unwell)
• FBC, EUC
• IDC (keep U/O > 40ml/hr)

EVALUATE CAUSE

DETERMINE SEVERITY

Indications of significant bleed

• Vomiting fresh blood
• Malaena
• Postural hypotension
• Tachycardia
• Hypotension
• Bright PR bleeding

FURTHER INVESTIGATIONS

• INR (in massive bleed or if suspected liver disease, coagulapathy)
• Endoscopy (should be done within 24-48 hrs to identify lesion, but does not alter natural history if no intervention)
• CXR (if suspected perforation or aspiration)

DEFINITIVE MANAGEMENT

IV Ranitidine/IV Omeprazole (no evidence this reduces the rebleed rate, transfusion requirement or length of hospitalisation)

Octreotide

Indications

• Suspected variceal bleed (history of liver disease, oesophageal varices, stimata of chronic liver disease)

Dose

• 50mg stat + 50mg/hr

Sengstaken-Blakemore Tube

Indications

• Severe bleeding AND

• Suspected variceal bleed (history of liver disease, oesophageal varices, stimata of chronic liver disease)
• Failed octreotide
• Acute endoscopic intervention unavailable
• Failed sclerotherapy

Acute endoscopic intervention

Indications

• Active bleeding/Recurrent bleeding
• Endoscopic finding of ?vessel on view/clot on view/flat spot)

Intervention

• Peptic Ulcer - Adrenaline/Co-aptive coagulation/Photocoagulation/Sclerotherapy
• Varices - Sclerotherapy/Banding

Surgical

Indications

• Failed endoscopic intervention
• Transfusion > 8 units/24 hours
• GI perforation

Interventions

• Peptic ulcer - vagotomy, pyloroplasty or gastrectomy
• Varices - Portocaval shunt, Ligation or Oesophageal transection

Other interventions

• TIPS (Transjugular Intrahepatic Porto-Systemic Shunt) - for variceal bleeding

DISPOSAL

Discharge if:

• Stable
• Bleeding stopped
• No haematemesis or malaena for 12 hours
• Mallory-Weiss Tear

Followup

• Refer patients to gastroenterology clinic for endoscopy
• Advise patients to return if further haematemesis or malaena
• Cease precipitants - NSAIDS, alcohol, smoking, steroids

Admit to HDU/ICU if:

• Continued bleeding
• Haemodynamically unstable
• Hb < 7g/dL or Hb fall of 3g/dL
• Elderly/Co-morbidities/Complications
• History of varices, AAA repair or anticoagulant use

Admit all others to ward

PROGNOSIS

By Clinical features

Good

• < 75 y.o.
• No comorbidities/No ascites/APTT normal
• SBP > 100 in first 60 min
• NGT - no blood in first 60 min
• History of previous Upper GI bleed
• Recent aspirin/alcohol use
• No further bleeding

Bad

• None of above features
• Red gastric aspirates
• Bright PR blood
• Rebleed
• Transfusion requirements = 4 Units on arrival or 1 Unit/8 hrs or initial HB < 8

By endoscopic findings/causative lesion

By endoscopic finding in peptic ulcers