Acute Upper Gastrointestinal Bleeding

Dr Ian Forgacs Consultant Gastroenterologist Kings College Hospital

Acute Upper GI Bleeding Annually

Incidence: 5050-100 per 10,000 Hosp admissions: 28,000 28 000 per annum Mortality: 3,000 deaths per annum

Acute Upper GI Bleeding - Deaths Proportion >60yo: >60 60yo: 60yo: 1920: 10% 1960: 25% 2000: 50%plus Mortality Mortality: : <60yo 4% >70yo 25%

How Acute Upper GI Bleeding presents:

Haematemesis Vomiting blood Melaena Passage of black black, tarry stools Rarely Syncope/Shock alone

Cli i l Assessment Clinical A t

History Examination Investigations Treatment Key factors 1) Assess severity of blood loss 2) ) Determine likely y bleeding g site

A Assessing i Severity S i History Patient Patients s account of blood loss unreliable Blood loss greater if both haematemesis and melaena Examination Physical examination v helpful Shock cool p peripheries, p , drowsiness Tachycardia (> 100/min) and hypotension (systolic bp< 90)

Potential Sites of Blood Loss

Peptic ulcer - gastric ulcer - duodenal ulcer Gastritis, , duodenitis, , erosions Reflux oesophagitis Oesophageal Varices MalloryMallory -Weiss syndrome Gastric carcinoma Other causes

25% 25% 20% 8% 4% 6% 2% 10%

Clinical Clues as to Bleeding Site

History Dyspepsia - peptic ulcer Liver disease - oesophageal varices Vomit then bleed MalloryMallory-Weiss Drug use - aspirin, NSAIDs, steroids

BUT: 1) 30% of patients with bleeding ulcer have no dyspeptic history 2) 50% of all patients give no useful clues

Clinical Clues as to Bleeding Site

Examination Stigmata of chronic liver disease Splenomegaly Abdominal mass, lymph nodes Purpura

1) 2) 3) 4)

BUT: Like the history, examination is often unrewarding

Immediate di Investigations i i

Full blood count (Hb and platelets) Electrolytes, urea, creatinine Prothrombin Time Blood Group (and crosscross-match 6 units)

Immediate Management

Haemoglobin Platelets Prothrombin Time Electrolytes, urea and creatinine Blood Group

Admit to hospital Set up IV line. Give saline, plasma expanders, blood Monitor p pulse, , bp, p, urine output, CVP Inform surgeons

Next Steps in Management

Resuscitation primarily fluid balance Stabilisation Upper pp Gastrointestinal Endoscopy py 1) Diagnostic 2) Therapeutic: adrenaline injection heater probe argon plasma coagulation

Case Presentation i -I
62yo woman Indigestion for 1 month - Postprandial abdo pain - Waking at night in pain - Partial relief by antacids Long history of rheumatoid arthritis Worsening joint pain Taking g more anti anti-inflammatory y drugs g

Case presentation i II

Decides to visit her GP On the way, way feels faint and vomits pints pints of fresh blood Ambulance takes her to hospital On Arrival: Looks pale and clammy Faint, Faint thready pulse Vague answers to questions Pulse: 120/min; BP: 95/60

Case Presentation i III

While being assessed, has large volume melaena, and pulse quickens Management: Intravenous infusion initially saline Urgent XX-match transfuse as soon as blood available Admit High Dependency Unit

Case C P Presentation i IV

Endoscopy - as soon as pulse/BP more normal Actively bleeding chronic duodenal ulcer locally injected with adrenaline S Seems to control l the h bleeding bl di Untilmore next week