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Unstable:
• Shocked
• Hypotensive
• Anaemic
• Transfuse >2U PRBC
Upper GI Bleed Resuscitation
• Two large IVCs or CVL
• Crystalloid
• FBC, ELFT, Coag Profile, X-M
• Transfusion if Hb low or high risk patient (eg. IHD)
• Correction of coagulopathy (INR>1.5) or thrombocytopaenia (<50,000/µl)
• Intubation: if ongoing haematemesis, altered respiratory status or mental
state
• Gastroenterology / Surgical consult
• All patients with haemodynamic instability (Shock, orthostatic
hypotension, decrease in haemotocrit of at least 6% or transfusion
requirement over 2U of packed RBC) should be admitted to ICU
Other resuscitation considerations
• Octreotide: May decrease risk of bleeding from non
variceal sources (Decreases bleeding by decreasing
splanchnic blood flow and inhibiting gastric acid
secretion)
• Erythromycin: Given 30-90min prior to endoscopy
can clear gut of pooled blood / clot by acting as
motilin receptor agonist
• PPI infusion: Reduces rate of rebleeding from ulcers
Rockall Prognostic Scoring
System
Variable Score 0 Score 1 Score 2 Score 3
A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortality
Diagnostic Studies
• Endoscopy: Highly sensitive and specific for locating
and identifying bleeding lesions in upper GI tract
• Helpful to irrigate stomach prior to endoscopy to
remove residual blood and other gastric contents
• Despite irrigation, stomach can be obscured by blood
– difficult to establish diagnosis
• If bleeding stopped spontaneously, second-look
endoscopy may be required
Other Diagnostic Studies
• Angiography
• Radio-labelled red cell scan
• UGI barium studies are contraindicated in the
setting of UGI bleeding as they will interfere
with subsequent endoscopy, angiography or
surgery
Endoscopy
Perform early diagnostic endoscopy (<24 hours) with
risk classification by clinical and endoscopic criteria
to assist in:
• Safe and prompt discharge of patients low risk
• Improvement of outcomes for patients with high risk
• Reduction of resource utilisation for patients with
either low or high risk
Endoscopic Treatment
• Thermal coagulation: Coagulating bleeding artery at
ulcer base
• Endoclips: Ligation of bleeding vessel
• Injection can slow bleeding and allow endoclips or
thermal coagulation: Adrenaline (1:10000), <1ml
Alcohol 98%, saline (tamponade effect)
• Fibrin sealant
• Argon plasma coagulation
Refractory Bleeding
• Recurrent bleeding after two endoscopic trial of
haemostasis
• Angiographic haemostasis: High risks surgical
patients
• Surgery: Recurrent haemorrhage, continued slow
bleeding with ongoing transfusion requirements,
haemodynamically unstable despite resuscitation.
Procedure includes oversew of artery, antrectomy,
pyloroplasty, gastrojejunostomy
Peptic Ulcer
• Previously up to 50% of
UGI bleed
• Overall incidence
decreased
• Proportion of bleeds
associated with NSAIDS
increasing
• Mortality: 5-10%
Peptic Ulcer
• Causes: Decreased gastric/duodenal mucosal
defence associated with NSAIDS or aspirin, H. Pylori
infection or both
• Ulcerated mass
• Endoscopic management
may allow time for formal
treatment strategies such
as resection
• If endoscopy
unsuccessful,
angiographic strategies
can be used
Dieulafoy’s Lesion