Gastroenterology - Upper GI Bleed Pathway

Patient With evidence of acute upper GI haemorrhage
FRESH RED haematemesis
OR
FRANK malaena

History/Examinations

inc. baseline observations (HR, BP, Temp, Resp Rate, Spo2, EWS, AVPU)

Investigations

IV access and bloods (FBC, U&E, LFT, G&S, INR, Fibrinogen, Venous Blood Gases)

Are there any features of shock?

(Heart rate >100bpm/ Systolic BP <100mmHg)

OR

Is there significant ongoing blood loss

OR

Is this a suspected variceal bleed?

Features of shock

• Urgent Senior review
• Keep NBM
  
• 2 large bore IV cannulas
• Commence Resuscitation
• Consider massive transfusion protocol if
exsanguinating haemorrhage
• Correct Anticoagulation
  (Click here for guidance)

SpR or Consultant to contact GI Bleed Consultant

If Suspected variceal bleed, give:

• Tazocin 4.5g IV TDS (If penicillin allergy – Ciprofloxacin 500mg IV BD)
• Terlipressin 2mg IV 4 hourly
• Refer to critical care if reduced conscious level
• Indications for surgical review (click here)

Senior Review

 

No features of shock

Calculate Glasgow Blatchford Score (GBS)

Click here to Calculate

Score of Zero
Suitable for discharge after first senior input?
Yes - Discharge on oral Omeprazole Request Outpatient OGD

No - Admit to AMU Ward 12
Discuss with on call Gastroenterologist and admit to AMU or Ward 12
Admit to AMU or Ward 12
Assess patient
Transfuse to Hb>8
Discuss with Endoscopy Nurse Co-ordinator on 3043 to arrange OGD (In house only)

Score of 1 - 2
Admit to AMU and observe for 4 hours
Suitable for discharge after first senior input?

Yes - Discharge on oral Omeprazole Request Outpatient OGD

No - Admit to AMU Ward 12
Assess patient
Transfuse to Hb>8
Discuss with Endoscopy Nurse Co-ordinator on 3043 to arrange OGD (In house only)

Score of >2
Discuss with on call Gastroenterologist and admit to AMU or Ward 12
Admit to AMU or Ward 12
Assess patient
Transfuse to Hb>8
Discuss with Endoscopy Nurse Co-ordinator on 3043 to arrange OGD (In house only)

 

All patients should have escalation levels asessed

• Consider ceiling of treatment
• Does patient fir criteria for Care of the Dying Person
  Plan – Click Here
• Consider Amber Care Bundle – Click Here
• Does patient fit criteria for Care of the Dying
  Person Plan – Click Here
  
  

Correct Anticoagulation for AUGH patients

• Keep Hb >80
• Transfuse 1 unit of platelets if count <50
• If Fibrinogen <1.5g/l give IV cryoprecipitate 10 units
• If patient on warfarin/sinthrone give Vit K and d/w haematologist to authorise PCC
• If on Heparin or NOAC, d/w haematologist

If patient has life threatening bleeding and has been on dabigatran (Pradaxa) treatment discuss with haematologist the administration of specific reversal agent idarucizumab (Praxbind) 2.5 g iv x 2. Two ampoules are held in A&E department

Suspected perforation/acute abdomen

• Refractory shock in exsanguinating haemorrhage