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)
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  

Points 

0

1

2

3

Age

 <60

60-79              

>80

 

BP + HR

 >100 + <100

>100 + >100

<100 

 

Co-morbidity

 

 

Heart failure

Major co-morbidity

Renal/liver failure

Disseminated malignancy

 
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
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)

Upper GI Bleed - references


international guidelines US: Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding. Barkun A et al. Ann Intern Med; 139 (10): 843-857, 2003

national guidelines UK/SIGN: Management of Upper and Lower Gastrointestinal Bleeding, 2008 (pdf)

review Gastrointestinal Bleeding. Khilnani N. Emerg Med; 37(10): 27-32, 2005



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