Upper GI Bleed
Upper GI Bleed - key facts
Authors: Natalie Acors and Jayne Eaden
Top Tips: Normal blood pressure does not exclude significant 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 |
Upper GI Bleed - background
The three main priorities are: (1) resuscitate the patient, and protect the airway; (2) identify the source of bleeding; and (3) organise definitive treatment, to stop bleeding
| 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 |
| Pathology - Bleeding DU |  |
| 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 Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Stanley AJ et al. Lancet; 373 (9657): 42-47, 2009 |
| 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 |
Upper GI Bleed - investigation
| 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 (A guide to commonly used liver tests, Carey WD, Cleveland Clinic, 03) 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) |
Upper GI Bleed - treatment
Reassess after 4h; it is a dynamic process
|
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: Cochrane: Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Dorward S et al, 2009 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 |
| Prescribing issues | Stop drugs (below) that may have 'caused' bleed |
| 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 |
Upper GI Bleed - the rest
| Maxim | '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) |
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| 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
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| Glasgow-Blatchford Score |
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 Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Stanley AJ et al. Lancet; 373 (9657): 42-47, 2009 and Proposed risk stratification in upper gastrointestinal haemorrhage: is hospitalisation essential? Courtney AE et al. EMJ: 21; 39-40, 2004 |
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| 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 |
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| 2°Prevention + Health Promotion |
Stop NSAIDs, alcohol Reconsider warfarin (assess risk:benefit) |
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| 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 |
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| Red flags |
• Rebleeding • Varices • Frail/elderly • Poor prognostic factors (see above) |