Management acute gastro bleed (part 2)

CVP line:
Consider for high risk patients eg increasing age, CV disease, on B-blockers.

Acute drug therapy:
Following successful endoscopic therapy in patients with major ulcer bleeding, IV omeprazole (80mg stat followed by 8mg/h for 72h) is recommended.
There is no firm evidence to support the use of somatostatin or antifibrinolytic therapy in the majority of patients.

Variceal bleeding:
Resuscitate then proceed to urgent endoscopy for banding or sclerotherapy. Give octreotide 50µg/h IVI for 2-5d. Terlipressin may also be used.
If massive bleed or bleeding continues, pass a Sengstaken-Blakemore tube.
A bleed is the equivalent of a large protein meal so start treatment to avoid hepatic encephalopathy.
Esomeprazole 40mg PO may also be helpful in preventing stress ulceration.

Endoscopy:
Within 4h if you suspect variceal bleeding;
within 12-24h if shocked on admission or significant comorbidity.
Endoscopy can identify the site of bleeding, estimate the risk of rebleeding and can be used to administer treatment.

No site of bleeding identified:
Bleeding site missed on endoscopy; bleeding site has healed (Mallory-Weiss tear or Dieulafoy's lesion); nose bleed (swallowed blood); site distal to 3rd part of the duodenum (Meckel's diverticulum, colonic site).

Rebleeds
Serious event: 40% of patients who rebleed will die. If "˜ at risk" maintain a high index of suspicion.
If a rebleed occurs, check vital signs every 15min and call senior cover.
To prevent rebleeding in endoscopically-proven high risk cases, IVI omeprazole has been tried, eg 80mg followed by an infusion of 8mg/h for 72h, then 20mg/24h PO for 8wks.

Signs of a rebleed:
Rising pulse rate.
Falling JVP decreasing hourly urine output.
Haematemesis or melaena.
Fall in BP (a late and sinister finding) and decreased conscious level.