‘A Yellow Bleeder’

Kaushik GuhaShirin Zaheri

Fariza Wan JamaludinShebina Hakda

HISTORY - MR. Y: 30y male, unemployed, known alcoholic liver disease PC - abdominal swelling and tenderness. *AMTS 7/10* HPC - Admitted 3.7.03 feeling unwell 3/7 with abdo pain & rigidity, SOB, loss of

appetite, nausea. - 4.7.03 : spontaneous haematemesis at 2350, throughout night. - Fresh, bright red blood with estimated loss: 3L. - Darkening of stool and urine since then - No itchiness SE - Weight stable, constipation, low mood & anxiety.

- No hx of previous haematemesis / NSAIDs / dyspepsia. PMH - Meningitis ‘91

- Cirrhosis due to ETOH few years ago. DH - NKDA

• Spironolactone -KCl• Insulin -Chlordiazepoxide• Pabrinex -Multivitamin supplements

• FH - No alcohol dependence problem and liver diseases in the family• SH - ETOH hx:

• Started drinking 15 years ago• Present consumption: 29 unit/day of mainly cider• Last drink was the day before admission.• Drinks by himself at home, rarely goes to the pub

• CAGE questionnaire Alcohol dependence : 7/7• 1. Cut down - Withdrawal symptoms: resting tremor, nausea• 2. Annoyed - Detox programme in Springfield March ‘03 but • 3. Guilt x unable to complete due to medical admission.• 4. Eye opener

• Started smoking at 14yrs. Now smokes 20-30 cigarettes /day. • Lives with father, he is very supportive.• Substance abuse - Nil• Forensic history - Nil

EXAMINATION - MR. Y:• Pulse: 90/min, BP: 135/75, Temp: 36.7, Sats: 99%. • App : Polite, alert, not encephalopathic. No further haematemesis.

• Palmar erythema - Xanthomas L palm.• Leuconychia - Bilateral yellow sclerae.• Multiple spider naevi on chest - Fine resting tremor

• CVS: Pulse 90, regular, sinus rhythm.• JVP not raised• HS I + II + 0 , loud S II

• RESP : Rate 28/min, decreased air entry bilateral lung bases.• ABDO: Distended, rigid, tense, mildly tender.

• Shifting dullness• liver enlarged 2 cm below R costal edge• no splenomegaly.

• NEURO: Unremarkable• DDX : Decompensated liver impairment secondary to ETOH

intoxication.

INVESTIGATIONS - MR Y:

1) FBC Hb 10.1 (13-17) WBC 6 (4-11) PLATELET 71 (150-450) MCV 95 (80-97) RBC 3.11 (4.5-6)

3) LFT BILIRUBIN 66 (<17) ALBUMIN 27 (35-48) ALT 18 (<52) GGT 148 (<50) ALP 85 (30-100)

2) BIOCHEMISTRY NA 123 (135-

145) K 4.2 (3.5-

4.7) CL- 96 (98-

109) HCO3 20 (22-32) UREA 2.1 (2.5-8.0)

CREATININE 43 (60-

110)

MANAGEMENT - MR. Y: Urgent endoscopy (OGD) 4.7.03 findings: - fresh blood in oesphagus - at least 6 varices with high risk stigmata, 1 varix spurting. - fresh blood with clots in stomach, unable to exclude gastric

varices as fundus not visualised adequately. Lower stomach and 1st & 2nd part of duodenum normal. 5 bands applied - bleeding stopped but blood reflux from stomach. F/U OGD 9.7.03 : 6 oesophageal varices no red signs / no further bleeding / no banding ulceration

F/U OGD 29.7.03: 4 oesophageal varices no red signs/ bleeding / ulceration F/U OGD due in 4 weeks.

EPIDEMIOLOGY:

HAEMATEMESIS: vomiting of blood from a lesion proximal to the distal duodenum.

Accounts for 2500 hospital admissions each year in UK.

Annual incidence varies, 47-116/100,000. Higher in low socio-economic areas. Hospital mortality approximately 10%.

CAUSES OF UPPER GI BLEEDS:

OESOPHAGEAL VARICES-1:

Increases in portal pressure cause development of a portosystemic shunt

Anamostoses with the systemic circulation are commonly found in oesophagus, superior and inferior epigastric veins (caput medusae), superior and inferior rectal veins

Causes can be divided between prehepatic, hepatic and post hepatic

Commonest causes in West are alcoholic and viral cirrhosis, worldwide schistosomiasis hepatic infection

OESOPHAGEAL VARICES -2:

OESOPHAGEAL VARICES-3:

GASTRIC ULCER:

MALLORY-WEISS TEAR:

Resuscitate - Airway- Breathing- Circulation

Assessment - History- Examination- Investigations

MANAGEMENT OF UPPER GI BLEED:

INITIAL ASSESSMENT:

• Enquire about drug usage (esp. NSAIDS), EtOH, retching, previous dysphagia and dyspepsia

• Examine for signs of chronic liver disease

• Check for melaena by PR

• Take blood for Hb, U&E, LFTs, Grp & Save/Crossmatch and coagulation studies

INITIAL MANAGEMENT:Suspected GI bleed

HIGH RISKLOW RISK•Hb > 10g/dL•<60 years and previously fit•Coffee ground vomitus•CVS stable•Allow fluids •Observe signs of continued or rebleed

EndoscopyNext routine listInform endoscopy by 9am

High risk ‘stable’Tachycardia > 100Postural hypotensionCo-morbidity

ResuscitateInform•GI Bleed reg (air call)

EndoscopyWithin 12 hours

Acute severeHypotensionHaematemesis/melaena

ResuscitateInform•GI Bleed reg (air call)•Surgical reg

EndoscopyAs soon as possibleSurgeon in attendanceGI bleed consultant informed

SECOND PHASE OF MANAGEMENT:

Varices Bleeding continues Bleeding stopped

•Banding•Sclerotherapy•Balloon tamponade•Urine output•Inform GI team•Prevent encephalopathy

High riskClose monitoringMeasure CVPInform GI bleed team

Low riskDiscuss mgmtwith GIB RegEarly discharge

Plan for re-bleed

Consultant endoscopy Surgery Radiological intervention

Options

RISK OF RE-BLEEDING: (Rockall Score)

SCORE 0 SCORE 1 SCORE 2 SCORE 3AGE <60yrs 60-79yrs 80yrs +SHOCK HR <100

systolic>100mmHg

HR >100 systolic

>100mmHg

HR >100 systolic <100mmHg

CO-MORBIDITY

None CCF IHD other

RF LF malignancy

ENDOSCOPY None Dark spot None Dark spot

blood in upper GI tract adherant clot active spurting vessel visible vessel within ulcer

DIAGNOSIS Mallory-Weiss

No lesion

All other dx Malignancy of upper GItract

POSTENDOSCOPY

SCORE

RISK OFDYING(% )

RISK OFRE-BLEED

(% )8+ 40 377 23 376 12 275 11 254 8 153 2 12

0-2 0 6

Calculate Risk:

• Re-bleeding in 50% in 10 days.• Prognosis worse in those admitted for other

reasons and subsequently have an acute upper GI bleed, than those admitted solely for bleeding.

• Recurrence thought to be 60-80% 2 years after initial bleed.

LONG-TERM PREVENTION OF A RE-BLEED:

Banding: repeated at 2 weekly

intervals, follow-up endoscopy.

any increase in survival?

Non selective beta-blockers (propanolol): HR at rest, portal pressure)

risk of re-bleedintolerance

Isosorbide Mononitrate – releases nitric oxide vasodilatation.

systemic vasodilatation renal function

Surgery – TIPSS (Trans-jugular Intra-hepatic Portal-System Shunt)

In portal hypertension of hepatic origin.

Failed endoscopy. Bridge to subsequent

liver transplantation. When successful

the shunt prevents recurrent variceal bleeding.Encephalopathy occurs in up to 25%.Intimal proliferation – shunt dysfunction.

Liver transplantation is the treatment of choice in advanced liver disease.

Portal hypertension and liver function restored.

Survival at 1 yr is 80% and at 5 yrs is 60%.

REFERENCES:

• Bosch J et al. Prevention of Variceal Bleeding. Lancet 2003; 361:952-54.

• Rockall TA et al. Risk Assessment after acute upper GI haemorrhage. Gut: 1996; 38:316-21.

• Kumar P, Clark M. (Eds) Clinical Medicine. 5th Ed. 2002. WB Saunders.

• Logan R, Harris A, Misiewicz J, Baron J. (Eds) ABC of the Upper Gastrointestinal Tract. 2002. BMJ Books.

• Ball C, Phillips R. (Eds) Evidence Based On Call: Acute Medicine Pocketbook. 2002. Churchill Livingstone.