Table of Contents Include in assessmentABCDE ManagementSpecific treatment Scoring systems Preventing further bleeding Test your knowledge with some questionsTry an OSCE stations Include in assessment Examination: ensure you look for signs of common causes (e.g. chronic/decompensated liver disease) and do PR exam (for melaena) Bloods: G&S/crossmatch, FBC (blood loss), U&Es (↑urea in GI bleeds), LFTs (varices risk), clotting (coagulopathy common in liver disease), glucose Catheterise (monitor UO) CXR and AXR once stable (e.g. for aspiration, obstruction) OGD Observations: check regularly ABCDE Management Follow usual ABCDE approach IV fluid resuscitation (aim for systolic blood pressure ~100) In massive blood loss, transfuse blood, FFP and platelets as per local massive haemorrhage protocol Blood transfusion if Hb <7g/L in variceal bleed, <8g/L in non-variceal bleed, or shock The patient must be haemodynamically stable before endoscopy Specific treatment Acute variceal bleed (suggested by history/signs/results consistent with chronic liver disease or portal hypertension): Terlipressin Prophylactic IV antibiotics Endoscopic intervention (variceal band ligation) Non-variceal bleed (e.g. peptic ulcer, Mallory-Weiss tear, oesophagitis): IV proton pump inhibitor Endoscopic intervention (adrenaline injection, clips, or thermocoagulation) In all patients: Keep NBM Transfuse as above Correct any clotting abnormalities On warfarin: prothrombin complex concentrate + vitamin K On direct oral anticoagulant: Idarucizumab for dabigatran; Andexanet alfa for apixaban/rivaroxaban; consider prothrombin complex concentrate for others/if not available ↓Platelets <50×109/L: platelet transfusion ↑INR (not due to warfarin): vitamin K (if INR ≥1.5) ± FFP (if INR ≥2) ↓Fibrinogen <1g/L: cryoprecipitate Stop any antiplatelets or anticoagulants Treat any concurrent issues, e.g. encephalopathy, alcohol withdrawal Other interventions that are less commonly used Balloon tamponade with Sengstaken-Blakemore tube Interventional radiology (embolisation) Surgical intervention Transjugular Intrahepatic Portosystemic Shunt (for resistant varices) Scoring systems Glasgow-Blatchford score (pre-endoscopy) Assesses likelihood patient will need intervention Score 0 = can manage as outpatient; score ≥1 = manage as inpatient) Takes into account haemoglobin, urea, SBP, sex, HR, presence of melaena, recent syncope, history of liver disease or heart failure (Blatchford et al. 2000) Rockall score (post-endoscopy) Mortality risk assessment Score ≤2 = good prognosis; score >8 = high mortality risk Takes into account age, shock, comorbidities, diagnosis and evidence of bleeding (Rockall et al. 1996) Preventing further bleeding Treat the cause/reduce the risk of re-bleeding: Oesophageal varices Carvedilol (β-blocker that reduces portal venous pressure) Variceal banding Transjugular Intrahepatic PortoSystemic Shunt Liver transplant Peptic ulcer Proton pump inhibitor H. pylori eradication if +ve Avoid precipitants, e.g. NSAIDs Reference: NICE ‘CG141 Acute upper gastrointestinal bleeding in over 16s: management’ 2016 Test your knowledge with some questions How does terlipressin work in a variceal bleed? Oops! This section is restricted to members. What is a TIPS? How is it undertaken and how does it work? Oops! This section is restricted to members. A patient has a TIPS and then becomes confused. What has happened? What is your initial management? Hepatic encephalopathy is a common complication of a TIPS procedure. Management is supportive with lactulose and rifaximin. Learn more about complications of cirrhosis here. Try an OSCE stations Upper GI bleed Find more here
