UGIB

Name Date
UR Hb
Urea

Gastroscopy Report

Varices? Somac, octreotide, and refer to decomp CLD protocol

Medications
Indication Cease? Restart?
Aspirin Yes / No /
Clopidogrel Yes / No /
Warfarin INR Yes / No /
NSAID Yes / No /
Steroid Yes / No /

Follow-up
Variceal Bleeding: Liver clinic /
PPI: Duration /
DU: HP7 7/7 Nexium 20mg BD, Amoxycillin 1g BD, Clindamycin 500mg BD
GU: Rescope / 52
IHD: Cardiology /
Obstructive Jaundice
Name
UR

Stones? if no stones on US -> CT cholangio or MRCP

Past History
Indication/type Timing
Prior Stent /
Lap Chole /
Panc Ca
Cholangioca
Liver mets

Follow-up
Cancer: Onc /
Stent inserted: Stent Change / 12

Stones: Lap Chole /

Date
Bili
ALT

Abdo US

CT cholangiogram (Bili<200) / MRCP (Bili>200/renal imp)

ERCP
Stent insertion

Sphincterotomy
Balloon trawl
Success Fail -> ?PTC

PTC
Ascending Cholangitis
Name Date
UR WCC
CRP
Bili
ALT
INR
Bcult

Stones? if no stones on US -> CT cholangio or MRCP

Past History
Indication/type Timing
Prior Stent / CT cholangiogra
Lap Chole /
Panc Ca
Cholangioca
Liver mets

Follow-up
Cancer: Onc /
Stent inserted: Stent Change / 12
Stones: Lap Chole /
 Abdo US

CT cholangiogram (Bili<200) / MRCP (Bili>200/renal imp)

ERCP
Stent insertion

Sphincterotomy
Balloon trawl
Success Fail -> ?PTC

PTC
Decompensated Chronic Liver Disease
Underlying cause
EtOH
NASH
Hep B
Hep C

Other

Last Abdo US:

Last Gastroscopy:

Complications Rx
Varices
Encephalopathy
Coagulopathy
Jaundice
Ascites
HRS

Child-Pugh score

1 2 3
Bili <34 34-50 >50
Alb >35 28-35 <28
INR <1.7 1.7-2.2 >2.2
Suppressed with
Ascites Nil meds Refractory
Enceph Nil G1-2 G3-4/ref

Points Class One year survival Two year survival

5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%

Gastroscopy

Ascites
Name
UR

Date
Bili
ALT
INR
Hb
WCC
PLT
K
Urea
Creat
Abdo US
Lesions -> if seen r/q CT liver
Portal thrombus
Cirrhosis
Splenomegaly

Liver Screen
Autoimmune
AMA
SMA
Anti- LKM

Genetic
Ferritin -> if grossly elevated r/q HFE
Copper
Caeruloplasmin
α1AT
Cancer screening
αFP
Viral
HBsAg
HBsAb
HBcAb
Hep C

Ascites
PMNs
Culture
Cytology
Urine
WCC
Culture
Sens/res
Hepatitis

Cause Type
Toxic

Viral

Ischaemic

Complications Rx
Encephalopathy
Coagulopathy
Jaundice
HRS

Child-Pugh score
1 2 3
Bili <34 34-50 >50
Alb >35 28-35 <28
INR <1.7 1.7-2.2 >2.2
Suppressed with
Ascites Nil meds Refractory
Enceph Nil G1-2 G3-4/ref

Points Class One year survival Two year survival

5-6 A 100% 85%
7-9 B 81% 57%
10-15 C 45% 35%
Name
UR

Date
Bili
ALT
INR
Hb
WCC
PLT
K
Urea
Creat
Abdo US

Liver Screen
Autoimmune
AMA
SMA
Anti- LKM
Genetic
Ferritin -> if grossly elevated r/q HFE

Copper
Caeruloplasmin
α1AT
Cancer screening
αFP
Viral
HAV
HBsAg
HBsAb
HBcAb
Hep C
Hep E
EBV
CMV
HIV 1&2
Pancreatitis
Name
UR

Stones->Lap/chole /
EtOH Addiction Medicine /
Post ERCP
Triglycerides
Other

Ranson Criteria
O/A 48/24
Age >55
WCC >16
BSL >11
LDH >350
AST HcT O/A >250
Hct ( - ) / = % <90%
Urea - = <-1.8
Ca <2
SaO2 <90%
HCO3 24 - = >4

Fluid rq >6L

Total

Score Mortality
0-2 = 2%
3-4 = 15%
5-6 = 40%
>7 = 100%
Date
WCC
CRP
Bili
ALT
Hb
INR
Na
K
Urea
Creat
Ca
Mg
PO4
Abdo US
Anaemia FI
Name
UR

Hb TF if <80/symptomatic
MCV
Retic
Urea
Iron
Ferritin if high -> sTFR, if low -> Fe infusion
Transferrin
TF sat

Gastroscopy

Colonoscopy

Follow-up
DU: HP7 7/7 Nexium 20mg BD, Amoxycillin 1g BD, Clindamycin 500mg
GU: Rescope / 52
CRCa: CR / 52 -> CT C/A/P
Gastr Ca: / -> CT C/A/P
Onc: /
NAD Pillcam /
1g BD, Clindamycin 500mg BD