HEPATOLOGY

VARICEAL BLEEDING

Introduction

5 min

Introduce yourself and the group

Provide rationale for the session and relevance to clinical practice

Outline learning objectives:

Demonstrate ability to a focused history from a patient presenting with upper GI bleeding
Perform an ABCDE assessment of a patient presenting with upper GI bleeding
Understand resuscitation of an acute bleed in an unstable patient and role of the major haemorrhage protocol
Appreciate management of variceal bleed in context of general management of decompensated liver disease
Prescribe appropriate medications in acute UGIB and liver disease (5th years only)

Explain structure of session

Total time:

60 min

Number of students:

1-5

Grade of students:

3rd to 5th year medical students

Created by:

Dr Philippa Clery

Uploaded:

26th September 2019

Last updated:

26th September 2019

Resources needed for this session:

Blood transfusion request form and bottle, pen, paper

Resources linked to this session:

Decompensated chronic liver disease

Upper GI bleeding (non-variceal)

Activity 1: History Taking and Examination

20 min

Ask the student(s) to take a focused history from a stable patient presenting with variceal bleeding. Before they see the patients ask them to consider specific questions to determine risk of variceal bleeding, e.g. known liver disease or possible risk factors for a new presentation of liver disease. Consider relevant alcohol and drug history.

If appropriate, ask students to examine the patient and report on any clinical signs of chronic liver disease.

Activity 2: Case Presentation and Case-Based Discussion

10 min

Ask the student(s) to present the key findings from their history and examination (if relevant). Feedback on presentation style (max 1 min).

Ask the student(s) to:

Suggest three top differential diagnoses and justification for these.
Suggest some initial investigations that may be useful and what they are expecting them to show.
Suggest an initial management plan for the patient.
Discuss the role of the Glasgow Blatchford or Rockall Score.

Activity 3: A to E Assessment

10 min

On the patient they have just seen, or a more stable patient if appropriate, ask students to perform an ABCDE assessment.

At each point, consider how they might assess for and treat any abnormalities, for example:

Circulation
- Assess HR, BP, gain wide bore IV access, take VBG and G&S
- Treat with fluids or blood transfusion, major haemorrhage protocol

For 5^th years: Ask the student(s) to find a G&S/blood transfusion request form and practice completing the details on the form.

Activity 4: Debrief

10 min

Discuss the student's approach to the assessment above.

For more junior students, consider:

When might you need to call for help?
How will you ask for help?
Who might you need to help manage the patient?
When do they need to go for urgent endoscopy?

For more senior students, consider:

How to activate the major haemorrhage protocol? You may wish to find this protocol and read through.
Discuss the use of O negative blood in emergency situations.
What medications may be used to treat variceal bleeding?
What are the considerations before prescribing these? (NB. Should be asking for senior input before giving terlipressin)

Activity 5: Prescribing

10 min

For more senior students, ask them to write a drug chart for this patient using the BNF.

Consider role of high dose PPI in this circumstance.
What drugs might they need to consider omitting given active bleeding?
Consider the patient's risk of alcohol withdrawal - ask students to prescribe an appropriate medication to prevent this.