Upper Gastrointestinal Bleeding

Andrew Rochford

Undergraduate Teaching

Overview

• Introduction

• Knowledge base

• Evidence base

• Summary

Introduction

• Patient Assessment

• Patient Resuscitation

• Further / Definitive Management

Acute Upper GI Bleed

• Case History

– 66 year old ♂

– Intermittent dyspepsia (takes Gavison)

– Recently much worse with vomiting

– Episode of fresh malaena

• What else do you need to know?

Additional information

• History– Previous peptic ulceration

– PMHx

– DHx• Aspirin / NSAIDs, Anticoagulation

• Steroids, Ca channel blockers, theophylline, nitrates

• Are they already on a PPI?

• Examination– Heart rate

– Blood pressure (including postural)

– Abdominal examination (inc. digital rectal exam)

Presenting Signs

Case History - 66 year old ♂

• PMHx

– Ischaemic Heart Disease

• DHx

– ACEI, B Blocker, Aspirin

• On examination

– HR 100 reg

– SBP 110

– Malaena on DRE

• Hb 9.2 INR 1.2 Urea 12

Facts & Figures

• Incidence of 50 – 150 per 100 000 per annum

– Increased risk in low socioeconomic groups

• Significant mortality & morbidity

Rockall et al 1993/4 AUGIB Audit BSG/NBS ‘07

Total numbers 4185 6750

Overall mortality 14% 10%

New Admissions 11% 7%

In patients 33% 26%

Surgery 7% 2%

AUGIB BSG/NBS ‘07

• 43% Transfused

• 60% Out of hours

• 26% Did not have an inpatient OGD

• Varices 8% from 4%

• Only 19% of patients had documented evidence of risk stratification

Rockall Score

Rockall, T A et al. Risk assessment after acute gastrointestinal haemorrhage BMJ 1995;311:222-226Palmer KR et al. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51(Suppl IV):iv1-iv16

Aetiology

• 50% of patients with documented varices will bleed from another source

Rockall, T A et al. BMJ 1995;311:222-226

Scoring Systems

• Forrest scoring system

(endoscopic findings) 1974

• Baylor bleeding score 1993

• Rockall Score 1996

• Cedars-Sinai medical centre predictive index1996

• Blatchford score 2000

Endoscopic stigmata

“5% of bleeding will be out of the reach of an endoscope”

Stigmata Prevalance (%) Rebleed (%)

Arterial Bleed 10 90

Visible vessel 25 50

Adherent clot 10 25

Clean ulcer base 35 <5

Blockson JM et al Surg Endosc 2004;18:186-92

Risk Stratification

Minor/

Moderate

• Young

• No co-morbidity

• No shock

• Hb >10

• May NOT need OGD

Major

• Old

• Co-morbidity

• Shocked

• Hb <10

Further Management

‘The first priority in management is to correct fluid losses and restore blood pressure’

Palmer KR et al. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51(Suppl IV):iv1-iv16

Patient Management

• A B C D E

• IV access & bloods

• Estimate severity of bleeding

– Mild / Moderate

– Severe

• Pharmacological management

Pharmacological Management• Fluid resuscitation (including blood)

– AUGIB accounts for 13% of RBC transfusions in UK (Wallis, 2006)

• PPI – 80mg Omeprazole po (mild/moderate – 61p)– 80mg Omeprazole iv (severe - £10.42)

• Correct any clotting abnormalities– Vitamin K, FFP, Platelets, Tranexamic acid

• Prokinetic– Metoclopramide and / or Erythromycin

• Terlipressin (1g qds iv)– If varices suspected– Marked caution with ischaemic heart disease

Proton Pump Inhibitors

• ↑ pH of stomach

– Platelet / clot lysis if pH <6

• No evidence for H2 Antagonists

• Effects re-bleeding & surgery *

– No benefit on overall mortality

• Debate about route of administration

– iv if NBM

– iv infusion if bleeding vessel at endoscopy

• Evidence base often flawed* If bleeding vessel seen at endoscopy

Additional Management

• Endoscopy– Recommend dual endoscopic therapy for bleeding ulcers

• Surgery– Failed endoscopic haemostasis

– Endoscopic re-bleeding despite ‘successful’ endotherapy

– One vs. Two attempts

• Helicobacter pylori eradication

• Sengstaken-Blakemore tube:– Uncontrolled variceal bleed

Sengstaken Blakemore Tube

Severe

• Admit to HDU

• Inform surgeons & anaesthetists

• Catheterise

• IV PPI

– Infusion for 72 hrs only if stigmata of high risk of re-bleed on endoscopy

• NBM

• Central venous access

• OGD when haemodynamically stable

Key References

1. Rockall TA, Logan RFA, Devlin HB et al. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. BMJ 1995; 331:222-6

2. Rockall TA, Logan RFA et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-321

3. Palmer KR et al. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51(Suppl IV):iv1-iv16

4. National Confidential Enquiry into Patient Outcome and Death. Scoping our practice: the 2004 report of the National Confidential Enquiry into Patient Outcome and Death. London: NCEPOD, 2004

5. Dallal HJ & Palmer KR. ABC of the upper gastrointestinal tract: upper gastrointestinal haemorrhage.BMJ 2001;323:1115-7

GI Bleed Summary

• Triage according to severity of the bleed

• Resuscitate the patient

• Appropriate pharmacological management

• Early endoscopy

• Inform surgical / anaesthetic colleagues early

Any Questions?