===== GI bleeding =====
====Upper GI bleed (UGIB)====
  *Upper GI bleeding can be divided into variceal and non-variceal causes, because of important differences in Mx strategies

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^ History   ^ Likely cause ^
|NSAID use, previous ulcer,systemic illness  ^Peptic ulcer disease/gastroduodenitis  |
|Alcohol excess, chronic liver disease, spider naevi, jaundice, hepatosplenomegaly, encephalopathy, ascites  ^//***__Varices__**// / portal hypertensive gastropathy  |
|Excessive retching and vomiting prior to haematemesis  ^Mallory-Weiss tear  |
|Weight loss, dysphagia  ^Stricture/malignancy  |
|Chronic reflux, bisphosphonate use  ^Oesophagitis  |
|Previous abdominal aortic aneurysm repair  ^Aorto-enteric fistula  |
|Chronic kidney disease  ^Vascular ectasia  |
|Recent endoscopic retrograde cholangiopancreatography  ^Post-sphincterotomy bleed  |
|Peritonitis  ^Perforated ulcer  |
|Cachexia/lymphadenopathy  ^Malignancy  |

[{{ :wiki:gastroenterology:ugib.png?300|  **causes of UGIB in UK**}}]
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====Assess Risk: ====
[{{ :wiki:gastroenterology:blatchford_score.png?300| **Blatchford Score**}}][{{ :wiki:gastroenterology:rockall_score.png?300|  **Rockall score**}}]
  *Blatchford score at first assessment, and
  *full Rockall score //**after**// endoscopy

  *A patient with a Blatchford score of 0,1 may be discharged with O/P endoscopy

  ***AIMS65 score** (not currently used in UK) probably superior to both in predicting I/P mortality, LOS and likely ICU admission
      *Score of ≥2 predicts high mortality - 1 point for each : Albumin <30, INR>1.5, alteration in mental state, sBP<90, age ≥65

==== Management ====
  *Transfusion if massive bleeding with blood, platelets and clotting factors
  *platelets not required if no active bleeding and haemodynamically stable.
  *prothrombin complex concentrate if taking warfarin
  *Do not use recombinant factor Vlla except when all other methods have failed
  *//**terlipressin**// for patients with suspected variceal bleeding at presentation
    *synthetic vasopressin analogue with relative specificity for splanchnic circulation
    *causes vasoconstriction leading to a reduction in portal pressure
    *also used in [[wiki:gastroenterology:Hepatorenal Syndrome]]
    *//**Dose:**// 1-2mg per 6/24
  *prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.
  *no evidence to support TXA in GI bleeding.

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====Lower GI bleeding====
  *Haemorrhoids
  *Anal fissure
  *Anorectal ulceration
  *Inflammatory bowel disease (IBD)
  *Coeliac disease
  *Diverticular disease
  *Ischaemic colitis
  *Infective colitis
  *Cancer (Lower GI)
  *Angioectasia
  *Drugs (NSAIDs, warfarin or DOACs)
  *Upper GI bleeding presenting as LGIB

**1st stratify as unstable vs stable:**
Unstable = shock index(SI) >1:
  *SI is defined as heart rate (HR) divided by systolic blood pressure (SBP)
  *SI greater than or equal to 1.0 was associated with 40% mortality
  *SI has a normal range of 0.5 to 0.7 in healthy adults.

**If stable, then risk stratify using Oakland score:**

A patient with an Oakland score ≤8, is classified as a MINOR bleed and suitable for discharge from A&E and referral for outpatient colonoscopy.
6% of patients presenting with LGIB have an underlying bowel cancer, hence, endoscopy within 2 weeks is indicated in higher risk cases.

A patient with an Oakland score >8 is classified as a MAJOR bleed, and is likely to benefit from hospital admission and colonoscopy on the next available list.

[{{ :wiki:gastroenterology:oakland_score_for_stable_lgib.jpg?300|**Oakland score**}}]
==References include:==
https://www.nice.org.uk/guidance/cg141\\  
[[https://www.rcpe.ac.uk/sites/default/files/jrcpe_47_3_bhala.pdf|J Coll Physicians Mx GI bleeding]]\\  
[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604275/|AIMS65 score]]\\ 
https://gpraj.com/gastroenterology/2019/10/12/lower-gastrointestinal-bleeding|\\ 
[[https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30848-5/fulltext|Lancet 2020: TXA in GI bleeding. HALT-IT trial]]\\