8/6/2019 48. Upper GI Bleed

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48. A 56 year old man presents with a 12 hr history of melaena. He smokes 15

cigarettes per day, consumes 50g of alcohol per day and has been taking

dicolfenac sodium for osteoarthritis in his right knee. At the time of admission

his pulse rate is 100 bpm and blood pressure 100/60. Discuss the investigation

and management of this patient.

Introduction

- This gentleman presents with upper GI bleeding (melaena)

- Differential Diagnosis

o Peptic ulcer bleeding

NSAID use

o Gastric or oesophageal varices

High alcohol consumption

o Mallory-weiss tear

o Oesophagitis/gastritis/duodenitis

o Malignancy

Cigarette smoking + high alcohol consumption

o Drugs

- At the time of admission the patient is in shock (HR > 100bpm + Systolic BP < 100mmHg)

suggesting that there has been significant blood loss

Initial Management

- Triage patient to acute bay

- Airway

o Assess and secure airway

- Breathing

o Assess breathing - Look, listen, feel

o Pulse oximetry

o 100% Oxygen with Hudson Mask

- Circulation

o Apply circulation monitoring devices HR, BP, ECG

o Insert 2 large bore (14-16 gauge) IV cannulas

o Bloods

Group and hold / Cross match 6 units of blood

FBC

Coagulation Studies

LFT

UEC

BSL

o Give resuscitation fluids

Initially 1L bolus of colloid infusion

If the patient remains shocked:

Give blood (group specific or O Rh- until cross match is done)

If the patient improves:

Start slow NS infusion (avoid in patients with decompensated liver

disease as it worsens ascites use 5% dextrose for maintenance)

o Correct clotting abnormalities

Vitamin K, FFP, platelet concentrate

o CVP

8/6/2019 48. Upper GI Bleed

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I would consider inserting CVP line in high risk patients (eg. Increased age,

CVD, on -blockers) to accurately monitor fluid status and blood pressure

o Catheterise and monitor urine output

Aim for >30ml/hr

- Continued Monitoring

o Monitor vital signs every 15 min until stable

o Once stable, monitor vital signs hourly

- Notify surgical team

- Ensure the patient remains NBM

History and Examination

Once the patient is stabilised I would take a focused history and examination

- History

o History of current GI bleed (melaena/haematemesis)

o History of previous GI bleed

o Past history of PUD, CLD, ETOH, bleeding disorders

o

Comorbidities including IHD, COPD, DMo Current medications

More detailed history of NSAID use

Use of any anticoagulants in addition to his NSAIDs

- Examination

o Signs of CLD

o PR for melaena

Further Management

- Endoscopy

o Upper GI endoscopy should be arranged following resuscitation of the patient

< 4hr if suspected variceal haemorrhage

< 24hr if ongoing bleeding

o Benefits of endoscopy

Identify the site and cause of bleeding

Varices v ulcer v malignancy

Estimate risk of rebleeding

Active arterial bleeding (80% risk); visible vessel (50%); adherent clot

(30%)

Administer treatment for haemostasis

Adrenaline

Sclerotherapy Variceral banding

- Omeprazole

o Give 40mg IV following endoscopy

o Reduces risk of rebleeding and need for surgery, but not mortality, in peptic ulcer

bleeding

- Monitoring

o Check FBC, UEC, LFT and coagulation daily

- NBM

o Keep NBM for 24hrs

o Allow clear fluids after 24hrs and light foods after 48hrs (as long as there is no

evidence of bleeding)