- Mortality of this condition is around 10% so prompt management is vital
2 distinct patient groups
- older with co-morbidities - highest mortality risk
- young & alcohol
- x2 more common in men
Peptic ulcer (DU & Gastric = 50%) / Gastric erosions
- Oesophageal or gastric varices
- Mallory-Weiss tear
- Gastric cancer
You will usually encounter this in A&E resus where there will be plenty of people to help. Just in case it happens to you on the ward at 3am……..
- Get a nurse to call for help; you cannot resuscitate someone on your own.
- Place 2 large 14G (brown) venflons in the antecubital veins and give fluid ++. It does not matter too much which fluid you use, just give it otherwise the patient may die. Crystalloids (as per ATLS are safest)
- Take blood from the venflon before you give the fluid for a crossmatch (8 units), clotting, and U&E. FBC is useful but not essential.
- Transfuse to maintain a hemoglobin level of 8-10 g. Early aggressive fluid resus will reduce mortality.
- The primary goal here is fluid resuscitation prior to definitive intervention (by endoscopy +/- surgery). The use of H2-receptor antagonists has not been shown to be effective in altering the course of UGIB. PPIs are more effective as they probably protect the ulcer clot from fibrinolysis.
- Get a nurse to get the crash trolley and have it next to the patient
- Get the patients notes to the bed and try and find out some history – alcoholic, varices, ulcer etc
- Put in a urinary catheter
- Do not attempt to put in a central line even if you know how to do it. You cannot resuscitate down one (remember Laplace’s law), the patient is likely to be uncooperative and you will waste valuable resuscitation time putting it in on your own. Central lines are useful after initial resuscitation to guide further fluid replacement.
- Give 10mg IV metoclopramide (makes the gastro-oesophageal sphincter contract)
- If the patient is distressed give 1-2mg IV morphine. Increase in 1-2mg aliquots every 5-10 mins
When your seniors arrive get on the phone to the lab and request:
- X-match 8 units + 4 units of FFP + 4 Units cryoprecipitate
- Clotting and U&E (+/- FBC)
- If the patient is in extremis fast bleep the anaesthetist if he/she is not already there
- If the patient is in extremis get the O-negative blood (from the lab if the haematology MLSO is on site, labour ward or A&E)
- Find out from switchboard who is on-call for endoscopy
Further / Definitive Management
- Joint medical / Surgical care optimises outcome
Urgent / Emergency OGD by anendoscopist experience in GI bleeding is essential
rebleeding characteristics at OGD
- active bleeding (pulsatile, oozing)
- visible vessel
- adherent clot
Available OGD techniques:
- sclerosant or epinephrine injection
- heater probe coaptive coagulation
- bipolar probe coaptive coagulation
- haemostatic clip placement
- laser therapy
- The choice of treatment modality is influenced by the size of the vessel.
- Surgical intervention should be considered with vessels larger than 2 mm in diameter
- Angiographic embolization considered in the high risk patient.
In the patient who has an ulcer with an overlying clot, attempting to remove the clot by target washing is critical.
- The findings under the clot help determine Tx needed
- rebleeding characteristics at OGD
- Rebleeding occurs in 10-30% of endoscopically treated patients.
- A second attempt at endoscopic control is warranted in most cases.
- Do not be fooled - surgery has a rebleed rate tooand mortality varies with the surgical intervention performed
Surgical options include:
- under-run ulcer
- partial gastrectomy
- total gastrectomy
- oesophageal transection
- Vagotomy is rarely performed these days
- Shunting & TIPPS - only in expert hands under specific condotions