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What are the differentials for UBGIT?
1. Variceal bleed
2. Non variceal bleed:
- peptic ulcer disease
- gastric/esophageal malignancy
- arteriovenous malformation (Dieulafoy's lesion)
- Gastritis/esophagitis
- mallory weiss tear
- aorto-enteric fistula
What is the management pathway for UBGIT?
1. Stabilize airway, breathing, circulation (use suction to suck out all NG aspirates and blood, also give oxygen via nasal prongs)
- send bloods: FBC, U/E/Cr, GXM, PT/PTT, LFT, ABG, Lactate
- ECG (to detect AMI), CXR (TRO perforation)
2. Adjuncts
- insert NG tube to prevent aspiration, allow gastric lavage prior to OGD (AVOID IN SUSPECTED VARICES)
- intubate (patient is obtunded/uncontrollable UBGIT)
- catheterisation
- early IV omeprazole (80mg bolus, then 8 mg/hr for 3 days)
- give IV somatostatin/octreotide + IV antibiotics if suspected varices
- withhold all anticoagulants/anti-platelets/NSAIDs
3. If in class 2 shock --> monitor and give fluids
- give 1 L normal saline, fast. Reassess patient response afterwards
- responder (will show sustained clinical and biochemical improvement)
- transient responder (KIV colloids, wait for GXM)
- non-responder (KIV colloids, E bloods, adjunct monitoring via CVP line--> stabilize patient before moving to scope room for emergency scope)
***give restrictive transfusion therapy to keep Hb > 7 g/dL
4. If in class 3,4 shock or active BGIT or suspected varices --> emergency OGD
What are the scores for a patient with UBGIT?
1. Rockall score (includes OGD findings, history, physical examination)
- score of 2 and below have low risk of re-bleed, score of 8 and above have 50% risk of re-bleed
2. Blatchford score (only clinical and lab results)
- Low risk = Score of 0. Any score higher than 0 is “high risk” for needing a medical intervention of transfusion, endoscopy, or surgery.
3. AIMS 65 score (prognosticates inpatient mortality rate)
- Albumin <30 g/dL
- INR >1.5
- Altered mental status (GCS<14)
- SBP <90 mmHg
- Age >65
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