Exploring Twitter-based Journal Club- Acute Transfusion in Upper GI Bleeds
Upper GI Bleeds - SH2013
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Transcript of Upper GI Bleeds - SH2013
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7/29/2019 Upper GI Bleeds - SH2013
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Upper GI Bleeds
SH
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Structure
Aetiology
Risk factors
Initial evaluation
Acute admissions
Scoring tools
Management overview
Specific treatment
Case studies
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Aetiology
Duodenal Ulcer
Gastric ulcer
Erosions
Oesophagitis
Mallory Weiss Tear
Oesophageal varices Neoplasms Zollinger Ellison syndrome
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Risk factors
RF for PUD: H-pylori
Alcohol use:
Acute MW tear
Chronic Oesophageal varices
Drugs
NSAIDs (Ibuprofen considered safest), Bisphosphonates
Antiplatelet/Anticoagulant use
(Iron supplements)
Recent abdominal surgery
Coagulopathy inherited vs aquired
AGE
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Initial evaluation
Symptoms
Haematemesis - active bleeding.
Coffee-ground vomitingslow/stopped.
Malaenafrequency?
Occult bleeds: anaemia fatigue, angina, SOB
Shock
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Vitals: hypotension, tachycardia - tennis rule.
General: Confusion? Pallor? Jaundice? Telangiectasia?
Abdo exam:
Organomegaly
Palpable masses
Peritonism/tenderness
Investigations
FBC anaemia, Hb, Hct, Plts, MCV
Baseline LFTs and U&Es (may show pre-renal AKI) Prothrombin time
Glucose
Serum amylase
Cross match 6 units
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Acute admissions
NBM. Closely monitor airway, clinical status, vital signs, cardiac rhythm
Two large bore IV lines (Green (14G) orGrey (16G))
Bolus infusions of isotonic crystalloid
Transfusion
pRBCsHb
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Scoring tools
Important as mortality rate 15%
NICE guidelines: ALL pts with UGIB need risk assessment.
First assessment: Blatchford scoreintervention.
Score > 6 needs interventionOffer endoscopy to unstable patients with severe acute upper
gastrointestinal bleeding immediately after resuscitation.
Offer endoscopy within 24 hours of admission to all other patients with
upper gastrointestinal bleeding.
After endoscopy: Rockall scoremortality
Score 8 high mortality.
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Rockall score
Components: - ABCDE (pre & post score. NICE post. SIGN both).
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Management overview
?
Endoscopy:
Variceal bleed
Non-variceal bleed
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Specific treatment
Non variceal bleeds
Endoscopic treatment:
1. Mechanical Rx: clips +/- adrenaline
2. Thermal coagulation + adrenaline
3. Fibrin or thrombin + adrenaline
PPIs: SRH on endoscopy (only for non-variceal bleeds).
IV omeprazole 80mg STAT, followed by infusion of 8mg/hourfor 72 hours.
Adrenaline not
monotherapy
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Specific treatment
Variceal bleeds
At presentation: Terlipressin and prophylactic
antibiotics (suspected).
Balloon tamponade to stabilise until endo.
Endoscopic treatment: band ligation
If not controlled transjugularintrahepatic portosystemic shunt.
Hepatic encephalopathy
Hepatic ischaemia
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Case studies
A. Gastric carcinoma
B. Gastric erosions
C. Oesophagitis
D. Oesophageal Ca
E. Oesophageal varices
F. MW tear
G. Peptic ulcer disease
H. Zollinger Ellison syndrome
32 year old woman who has been investigated for 1 year for
recurrent peptic ulceration, is admitted with haematemesis.Ranitidine failed to control symptoms, and she is taking
Omeprazole 40mg OD.
Endoscopy 2cm actively bleeding ulcer in duodenum.
CT 2cm mass in pancreas
73 year old man presents with several episodes of coffee-
ground vomiting. 5 month Hx of epigastric discomfort, nausea,anorexia (+ inability to eat normal sized meals) and weight loss.
FBC Hb 7.9/dl, MCV 76.6 fl, WCC 5.3 x 109/L, plts 333 x
109/L, INR 1.1
22 year old med student comes to ED after the annual college
beer race. After vomiting several times he notices bright redblood in the vomitus. He had only consumed 12 pints of beer
(as is the custom to complete the race).
FBC Hb 14.2 g/dl, MCV 85.6 fl, WCC 8.2 x 109/L, plts 450 x
109/L, INR 1.0
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Thank you for listening