Airway
Early RSI by senior anaesthetist if:
- Severe uncontrolled haemorrhage.
- Severe encephalopathy.
- Inability to maintain oxygen saturation.
- Aspiration pneumonitis.
Breathing
- High flow oxygen via reservoir bag.
- Saturation monitoring.
- Check for aspiration or infective pneumonia.
- Blood gases (beware bleeding if arterial sample).
- CXR.
Circulation
- Intravenous access- minimum 2 x 16 gauge cannulae.
- X-match 6 units of blood, ( FBC, U&Es, clotting, LFTs).
- IV fluid – crystalloid (not colloid), then blood.
- Aim for systolic BP 80 - 90 mmHg [permissive hypotension (Ref)].
- Correct PTT
- Central venous access (compressible site ).
- Pressure monitoring (ideally correct clotting first).
- Catheterise (monitor hourly output).
- Vitamin K 5 mg slow IV and prothrombin complex concentrate 50µg/kg or FFP 15ml/kg, ± platelets.
Stop the bleeding
Therapeutic
- 2mg Terlipressin [Cochrane] in all unstable patients (beware myocardial ischaemia - treat with GTN patch or infusion).
- Call on call endoscopist via switchboard.
- Scoping will confirm Dx and allow band ligation.
- May be performed as soon as patient stable.
- May be performed as a life saving procedure in any critical area.
Balloon tamponade (Senstaken tube)
- Must always be preceded by airway protection (ETT) and sedation.
- Is reserved for severe uncontrolled haemorrhage and should be discussed with the on-call endoscopist prior to use.
- Inflate the gastric balloon and apply continuous gentle traction. It is rarely necessary to inflate oesophageal balloon.
At CUH, patients presenting hypotensive (Sys BP < 100mmHg) or Hb < 10 g/dl should be admitted under the surgical team on call. (Letter)
Further management
- Prophylactic antibiotics [Cochrane]
- [NICE] (Ciprofloxacin or Ceftazidine) in confirmed variceal bleeds (Ref )
Differential diagnosis
- Peptic ulceration, Portal hypertensive gastropathy
- Gastric or duodenal varices
- Aorto-enteric fistula
Reference
Gav P, Chapman R. Modern Management of Oesophageal varices.
Postgrad Med J. 2001;77:75-81
Bernard B, Grange JD. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999;29:1655-61