Upper GI Bleed

Key Differential Diagnosis

Lower GI bleed
Haemoptysis
Epistaxis (blood swallowed then vomited)

Key Investigations

FBC
U+E, LFT/GGT, Bone, Glucose ± Amylase
INR, G+S/Cross-match 2-6 units (dependent on severity)
ECG, Erect CXR (perforation?)
Rockall score (pre-endoscopy)

Key Treatment

IV OMEPRAZOLE 40 mg od
IV METOCLOPRAMIDE 10-20 mg stat
  ± Transfuse if appropriate
    ± IV TERLIPRESSIN 2mg IV stat (history suggestive of varices)
    ± IV VITAMIN K 10 mg slowly/FFP
    ± Platelets

Key Management Decisions

Resuscitate
Endoscopy
Surgery

Introduction

• Haematemesis is vomiting of red blood and indicates upper GI bleeding, usually from an arterial source or varix. Melaena is a black, tarry stool and typically indicates upper GI bleeding; but bleeding from a source in the small bowel or right colon may also be the cause
• Only 100-200 mls of blood in the upper GI tract is required to cause melena, which may persist for several days after bleeding has ceased
• 80% resolve spontaneously, with no intervention at endoscopy (or surgery)
• Some patients with minor GI bleeds (especially if suspected Mallory Weiss tear) may not need an endoscopy and some can be managed as an outpatient
• Mortality is 10%, 30% in the elderly, 30% if rebleed. This has not changed in 50 years; despite advances in endoscopic techniques, ITU care etc
• Coffee ground vomit is not always due to GI bleed
Note: PPI and early endoscopy do not reduce mortality. Good resuscitation might. So, senior review ASAP if unwell, or Rockall Score ≥ 3

Definition 

Bleeding from upper GI tract, resulting in haematemesis (hematemesis) and/or melaena.  Consider as a differential in patient with sudden onset collapse/shock

Epidemiology

50-150 per 100,000 per year (incidence)

Causes

Big 4 causes are:
1. Oesophagitis/gastritis/duodenitis (40%)
2. Chronic/acute peptic ulcer (duodenal > gastric); 25%, 1/3 taking NSAIDs
3. Mallory-Weiss tear (alcohol history, vomiting+)
4. Oesophageal/gastric varices, eg in portal hypertension
Note: Malignancy is rare (5%) but significant
[Ref]

Risk factors

NSAIDs
Alcohol/smoking
Chronic liver disease

Symptoms

Haematemesis/melaena (Gk melas = black)/coffee grounds
Notes: ascertain quantity and frequency of blood. However, quantity can be difficult to assess because even small amounts (5-10 mls) turn water in a toilet bowl an opaque red; and modest amounts of vomited blood appear huge to an anxious patient in a subacute bleed. Melaena may show itself tomorrow
Syncope/dizziness
Dyspepsia/epigastric pain
Weight loss

Key questions

"Have there been any changes in your tablets in the last 4-6 wks?" esp NSAIDs/warfarin)
"Have you ever been a heavy drinker (of alcohol)?"
"Do you feel faint when you sit up?"
Note: ask about other risk factors for liver disease

Signs

Of hypovolaemia: hypotension = systolic BP < 100 mmHg (lack of, does not exclude significant bleed, see below), tachycardia, sweating, pallor
Postural hypotension = postural drop >10mmHg
Urine output <0.5ml/kg/hour
Stigmata alcohol/liver disease
Rectal examination is mandatory (melaena?)
Note: look for rare causes of bleeding (Osler-Weber-Rendu)

4 assessment problems

1. Patients do not necessarily drop their Hb acutely. It takes several hours for haemodilution to occur. So, a normal HB does not exclude a significant bleed; and you should not wait for Hb to decide whether to transfuse or not
2. Older patients (especially those on rate limiting drugs, eg beta-blockers) cannot produce a tachycardic response to hypovolaemia. They tend to experience hypotension after relatively small losses
3. Conversely, younger patients can suffer a major loss before decompensating and dropping BP. Hence a normal BP does not exclude a significant bleed
4. A raised urea in the presence of a normal creatinine indicates a significant GI bleed, not renal failure

Blood

FBC
U+E, LFT/GGT, Bone, Glucose ± Amylase (if abdominal pain)
Note: leucocytosis common; platelets increased in subacute bleeding; or decreased in portal hypertension, leading to hypersplenism); urea may be raised, due to protein load 
INR, G+S or Cross-match if unwell (2-6 units)

Liver screen, if appropriate [Ref]
ABG, if unwell

Other

CXR (gas under diaphragm?; though bleed and perforation rare together)

Key investigations

FBC
U+E (urea rises when blood is digested in the GI tract – raised urea with a normal creatinine suggests a significant bleed)
INR

Specialist investigations

Endoscopy (identification of cause in >90% and permits treatment); but early endoscopy does not improve mortality

Differential diagnoses

Lower GI bleed
Haemoptysis
Epistaxis (blood swallowed then vomited)

Treatment
(first line)

Drugs
IV OMEPRAZOLE 40 mg od (in severe non-variceal bleed);
Note: IV omeprazole only of benefit in those that are high risk (judged after endoscopy, by requiring endoscopic therapy). No firm evidence of benefit pre-endoscopy: [Ref]
IV METOCLOPRAMIDE 10-20 mg stat
± TERLIPRESSIN 2 mg IV stat, if variceal bleed suspected (then continue 1-2 mg qds)
± IV VITAMIN K 10 mg, slowly/FFP (if variceal bleed suspected or INR >1.3)
± Platelets, if clotting abnormalities

Procedures
Protect the airway
Insert 2 large bore cannulae
IV fluids if hypovolaemic (systolic BP < 100 mm Hg or HR > 100); do not wait for the Hb
Use colloid initially; if only have crystalloid, then use 5% dextrose if liver disease, then:
Blood (aim for haemoglobin 10 g/dl); in emergency, give O negative blood – Aim to keep systolic BP >100 mmHg but not much higher than this (may increase likelihood of bleeding)
Watch for signs fluid overload (especially elderly, CRF, CCF)
Reassess after 4h, or earlier; give FFP, if transfused > 4 units
Nil by mouth, until endoscopy

Key management decisions

Transfuse/not
Endoscopy/not – Indications for urgent endoscopy:
1. Variceal bleed suspected
2. Continued bleeding requiring > 4 units blood to maintain systolic BP > 100mmHg
3. Rebleed after resuscitation
4. Any patient with a ‘Rockall’ pre-OGD score = 2 or more (see table below)
5. Surgery/not

Stop

Aspirin
NSAIDs/warfarin/other anticoagulants
Antihypertensives
Diuretics
Prednisolone?

Treatment
(second line)

Procedures
If unwell, CVP line (maintain at +5 cm H20), urinary catheter (maintain UO > 30 mls/h), arterial line
± Sengstaken tube (varices)
± Surgery

Admit?

Usually; but >10% of GI bleeds can go home; if fulfill all low-risk criteria of Glasgow-Blatchford Score (GBS) (see below)

Bed plan

Ideally gastroenterology ward
Otherwise medical admission ward
± ITU

Referrals

Medical      
Gastroenterology
± General surgery
± ITU

Other
Community alcohol service

'If you don't out your finger in it, you will put your foot in it'

Complications

Hepatic encephalopathy, if also has chronic liver disease
ARF (hypovolaemia)

Rockall Score (pre-endoscopy)

Rockall Score (pre-endoscopy): Total maximum score 7. Mortality 0-2 = 0%, 3 = 3%, 4 = 5%, 5 = 11%, 6 = 7%, 7 = 27%; 0-1 consider discharge; 2 or more consider early endoscopy; 3 = senior review ASAP

Low-risk criteria of Glasgow-Blatchford Score: if all present (ie GBS 0), can be managed as outpatient:
• Urea <6·5 mmol/L
• Haemoglobin ≥130 g/L (men) or ≥120 g/L (women)
• Systolic blood pressure ≥110 mm Hg
• Pulse <100 beats per min
• Absence of melaena, syncope, cardiac failure, or liver disease
[Ref]  and  [Ref]

Prognosis

80% resolve spontaneously, with no intervention at endoscopy (or surgery)
Mortality
10% mortality
30% mortality if >90 yrs
30% mortality if rebleed (25%)
Poor prognostic indicators include: old age, shock, rebleeding, varices, comorbidities (eg CRF, CLD, CCF, COPD), bleeding diathesis, drowsy

2°Prevention + Health Promotion  

Stop NSAIDs, alcohol
Reconsider warfarin (assess risk:benefit)

Don't forget

• Rectal examination is mandatory
• Reassess after 4h
• PPI and early endoscopy do not reduce mortality
• Good resuscitation might. So, senior review ASAP if unwell, or Rockall Score ≥ 3
• Normal BP does not exclude significant bleed
• Normal Hb (initially) does not exclude significant bleed
• Ring gastro team/surgeons/ITU early, if patient unwell
• Correct coagulation/platelet abnormalities

Red flags

• Rebleeding
• Varices
• Frail/elderly
• Poor prognostic factors (see above)