Thursday 18 November 2010

MRCP revision battle 53.5: Upper GI bleeds

Upper GI bleeds may present with:
  • haematemesis (=vomiting blood)
  • coffee ground vomiting or
  • malaena (=black, tar-like motions)

Commonest causes of upper GI bleeds are:
  • 35% duodenal ulcers
  • 20% gastric ulcers
  • 18% gastric erosins
  • 10% Mallory-Weiss tear
 

Rarer causes of GI bleeds include:
  • variceal haemorrhage
  • aorto-enteric fistula
  • Meckel's diverticulum
  • Peutz-Jeghers syndrome

Risk of rebleeding and mortality from upper GI bleeds is calculated using the Rockall score.
Pre-endoscopy Rockall score is calculated based on:
  • age
    • 0pt <60yrs
    • 1pt 60-79
    • 2pts >80
  • degree of shock
    • 0pt: BP >100 sys and HR <100
    • 1pt: BP >100 sys but HR >100
    • 2pts: BP <100 sys
  • co-morbidities
    • 0pt: none
    • 1pt: heart problems
    • 2pts: liver/renal failure
    • 3pts: mets

Mortality is roughly:
  • 1 in 20 with 2 pts
  • 1 in 10 with 3 points
  • 1 in 4 with 4 points
  • 1 in 2 with 7 points

Post endoscopy mortality is calculated based on the initial score, the diagnosis and the signs of haemorrhage seen.

Below is a summary of the Rockall score from the SIGN guidelines:



Management of upper GI bleeds is:
  • classic ABC resuscitation
  • if cause suspected to be variceal haemorrhage: IV terlipressin 2mg then 2mg/4hr
  • urgent endoscopy
  • surgery if endoscopy unsuccessful
  • if cause is ulcer: omeprazole after endoscopy
  • if cause is variceal haemorrhage: consider transjugular intrahepatic portosystemic shunt to prevent rebleeding (note: nearly 25% of people with a TIPS get hepatic encephalopathy)


Now to Meckel's diverticulum...