UPPER GASTROINTESTINAL BLEEDING

Bleeding from the upper gastrointestinal tract (oesophagus, stomach and duodenum). It can be a medical emergency.

Cause

  • Gastro-oesophageal varices
  • Peptic ulcer disease/severe gastritis/cancer
  • Mallory Weiss tear (a tear in the oesophageal mucosa caused by forceful retching)

Clinical features

  • Vomiting of fresh blood (haematemesis)
  • Coffee brown emesis (degraded blood mixed with stomach content)
  • Melena: passing of soft dark red smelly stool
  • Black stools (in case of minor bleeding)

Complications

  • Acute hypovolaemia (if acute and abundant): syncope, hypotension, tachycardia, sweating
  • Chronic anaemia (if subacute/chronic loss)

Diagnosis

  • Endoscopy

Management

Supportive treatment

  • Refer/admit to hospital
  • IV line(s) and IV fluids (Normal saline or Ringer’s Lactate), start with 500 ml in 30 minutes and adjust according to BP
    • Aim at systolic BP >90 mmHg and HR <105 bpm
  • Blood grouping and crossmatching
    • Hb may not reflect the amount of acute loss, consider amount of bleeding and clinical status to
      decide for blood transfusion
  • NGT and nothing by mouth (NPO)
  • Urinary catheter
  • Monitor vitals every 15-30 minutes
  • Stop antihypertensives and diuretics
  • Correct coagulopathy if present (e.g. in warfarin overdose, liver cirrhosis) with vitamin K 5 mg
    slow IV and fresh frozen plasma

PUD, gastritis

  • Ranitidine 50 mg IV every 8 hours (switch to oral omeprazole when possible, test for H.pylori)

Oesophageal varices

  • Refer for endoscopic treatment and prophylaxis with beta blockers