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home - Stomach - Clinical Presentations of Gastric Conditions - Upper GI Bleed Treatment Guidelines Written by Dr Sebastian Zeki
Nausea and Vomiting:
Understands the pathophysiology of vomiting.
Appreciates the gastrointestinal conditions that cause nausea and
vomiting as well as the range of extra-intestinal causes

Recognises the influence of neurological conditions and metabolic
derangements such as diabetes

Understands the physiology of gastric emptying and how this is
affected by disease, toxins and drugs

Abdominal Pain:
Knows the causes of acute and chronic abdominal pain that arise
from upper gastrointestinal, biliary and pancreatic diseases

Understands the clinical presentations of the various conditions
causing pain and the means by which they can be diagnosed and
treated

Weight Loss:
Knows the significance of weight loss as a consequence of upper
gastrointestinal disease, knows those conditions that present with
loss of weight and how they are managed

Skills
Makes a detailed clinical assessment of patients presenting with
symptoms indicating possible upper gastrointestinal disease,
construct a management plan and be aware of the various avenues
of treatment

Behaviours
Evaluates patients in a structured and timely manner, carries out
appropriate investigations and formulates management plan.

Upper GI Bleed Treatment Guidelines

(Endoscopic score) 1A - spurting 1B - oozing 2A - visible vessel 2B - clots 2C - Black spot at base 3 - clean Acid SuppressionPPI reduces risk of rebleeding.iv PPI Before endoscopy reduces bleeding signs but no effect on mortality.H2 No good really for ulcers.Oral PPI for bleeding.High dose of oral omeprazole (40 mg PO BID) was associated with a decreased risk of recurrent bleeding in patients who had ulcers with a visible vessel or adherent clots who did not undergo endoscopic therapy. Active bleeding during endoscopy 90 % recurrence Visible vessel 50 % recurrenceAn adherent clot 25 to 30 % recurrenceBlack or red spot at base negligeable rebleed rate Endoscopic TherapyThe use of combination therapy (adrenaline + one other therapy) reduces the mortality from 5.6% to 2.6%.Clips are more effective than epinephrine alone, but not different than other therapies.The efficacy of endoscopic therapies for clots was uncertain.Thermal coagulation has the same efficacy as adrenaline if used alone.Thermal coagulation should be used until area is blackened and cavitated.If Injection therapy with adrenaline is given alone, the rebleeding rate is high (18 %).Use 13ml 1:10,000 adrenaline.Mechanical Therapy is more effective than adrenaline aloneArgon plasma coagulation-can be effective although it doesnt involve tamponade. SOMATOSTATIN AND OCTREOTIDESomatostatin or octreotide can be used as adjunctive therapy before endoscopy, or when endoscopy is unsuccessful, contrain-dicated, or unavailable due to its splanchnic vasoconstrictive effectsTypical dose of somatostatin is 250 mcg then hourly for 3-7d while a typical dose of octreotide was 50 to 100mcg then 25mcg/hr for up to 3 days. Rockall Score (predicts rebleeding and death) If the initial (pre-endoscopic) score > 0 then significant mortality (score 1: 2.4%; score 2: 5.6%) Indications for Endoscopy Within 24 hours:Active bleeding.-Haematemesis ongoing.-Fresh melaena ongoing.-Hypotension or sinus tachycardia not responsive to resuscitation.-Persistently low Hb despite transfusion. Indications For Endoscopic Therapy:-Active bleeding.-Visible vessel.-Adherent clot if technically possible -snare adherent clots if cant be removed with suctioning/ irrigation. Repeat EndoscopyRepeat if difficult endoscopy or rebleed likely to be life threatening.Repeat OGD can reduce rebleeding rates but doesnt confer survival benefit. RebleedGastric ulcers along the lesser curvature and duodenal bulbar ulcers in the posterior wall appeared to be at greater risk for severe bleeding or rebleeding compared with ulcers in other locations because of their proximity to large underlying arteries (left gastric and posterior gastroduodenal arteries, respectively).Options: Surgery and transcatheter arteriography/intervention (TAI) are equally effective following failed therapeutic endoscopy, but TAI should be considered particularly in patients at high risk for surgery.TAI is less likely to be successful in patients with impaired coagulation.TAI is the best technique for treatment of bleeding into the biliary tree or pancreatic duct. Resuscitation Endoscopy Acid Suppression Upper Gastrointestinal Bleeding Management Sur-gery Angiogra-phy Repeat OGD Cause of bleeding:Peptic ulcer.Oesophagitis.Gastritis/ erosions.Erosive duodenitis.Varices.Portal hypertensive gastropathy.Malignancy.Mallory- Weiss Tear.Vascular Malformation. Relative frequency44282615137553 Age Shock Comorbidity Diagnosis Major stigmata of recent haemorrhage 0 1 2 3 >60 60-79 >80 Not shocked Tachycardia Hypotension None CHF/ IHD/ any major Renal failure/ liver failure/ disseminated malignancy None or dark spot only Blood in upper GI tract/ adherent clot, visible or spurting vessel Forrest classification Blood loss volume (ml) Blood loss (% of circulating blood) Systolic blood pressure Diastolic blood pressure Pulse (beats per minute) Respiratory rate Mental state Class I Class II Class III Class IV <750 750-1500 1500-2000 >2000 0-15 15-30 30-40 >40 No change Normal Reduced Very reduced/ unrecordable No change Raised Reduced Very reduced/ unrecordable Slight tachycardia 100-200 120 (thready) <120 (very thready) Normal Normal Raised (>20/min) Raised (>20/min) Alert, thirsty Anxious or aggressive Anxious, aggressive or drowsy Drowsy, confused or unconscious Adapted from Baskett, PJF. ABC of major trauma. Management of Hypovolaemic Shock.BMJ 1990; 300: 1453-1457

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