UGIB

• Differentials of UGIB:

  • Peptic ulcers (duodenal most likely to bleed)
  • Oesophageal varices
  • Gastritis
  • Oesophagitis
  • Malignancy
  • Boerhaave - rupture of oesophagus
• Mallory Weiss tear is a longitudinal mucosal tear or laceration of the mucous membrane in the region of the gastro-oesophageal junction
• Risk factors for Mallory Weiss tear:

  • History of retching, vomiting or straining
  • Chronic cough
  • Hiatal hernia
  • Endoscopy
  • NSAID and aspirin use
• Signs and symptoms of a Mallory Weiss tear:

  • Presence of risk factors (e.g. persistent vomiting)
  • Haematemesis
  • Melena
  • Feeling faint upon sitting/standing up
  • Can become haemodynamically unstable
• Investigations for Mallory Weiss tear:

  • Upper GI endoscopy is diagnostic
  • FBC, U&E and LFTs
  • Cross matching
  • Assess blood loss and fluid status
  • ECG and cardiac enzymes if indicated to assess myocardial ischemia related to acute blood loss
• Most patients with a Mallory Weiss tear will stop bleeding spontaneously. Some will need endoscopic intervention:

  • Clipping with or without adrenaline
  • Thermal coagulation with adrenaline
  • Thrombin or fibrin with adrenaline

  Offer PPIs/H2 receptor antagonists depending on results of endoscopy
• The Rockall score is used to assess risk of re-bleeding post treatment
• Oesophageal varices are dilated submucosal distal oesophageal veins connecting the portal and systemic circulations that are a result of portal hypertension. Rupture of these varices leads to a life threatening upper GI bleed.
• Management of oesophageal varices:

  • Terlipressin at presentation (vasopressin analogue that causes reduction in portal pressure)
  • IV antibiotics
  • First line treatment is band ligation
  • Consider TIPS procedure if bleeding not controlled by band ligation
• Upper GI bleeding can worsen hepatic encephalopathy - presence of blood in the GI tract results in increased ammonia and nitrogen absorption from the gut
• Boerhaave’s syndrome is a transmural tear of the oesophagus from a sudden increase in intra-oesophageal pressure such as extreme straining
• An erect XR should be done to look for air under the diaphragm (perforation)
• Resus with other blood products:

  • Platelets
  • FFP - useful when high INR
  • Cryoprecipitate - useful when low fibrinogen, haemophilia A or von Willebrand disease causing bleeding
• Glasgow-Blatchford bleeding score is used to score risk in UGIB patients:

  • 0 - lower risk, consider OP treatment
  • >0 - higher risk of needing intervention
  • Score of 6 or higher - more than 50% risk of needing an intervention
• The rockall score is completed after endoscopy and identifies patients at risk of adverse outcome following acute upper gastrointestinal bleeding