Safwat, J Gastroint Dig Syst 2013, S3

DOI: 10.4172/2161-069X.S3-004

Review Article Open Access

J Gastroint Dig Syst Gastrointestinal Disease Treatment ISSN: 2161-069X JGDS, an open access journal

Management of Non Variceal Upper Gastrointestinal BleedSherif Safwat*Mid Essex Health Authority, UK

AbstractUpper gastrointestinal bleeding has 10% in-hospital mortality. Despite significant advances in the management, there

has not been any improvement in mortality. The only improvement over the last 25 years has been in variceal bleeds. Increasing age and comorbidities are the major factors related to mortality. Early endoscopic management of severe upper GI bleeds improves survival. Adopting a system which identifies severe bleeding and vulnerable patients is essential.

*Corresponding author: Sherif Safwat, Mid Essex Health Authority, UK; E-mail: Sherif.Safwat@meht.nhs.uk

Received March 08, 2013; Accepted March 31, 2013; Published April 02, 2013

Citation: Safwat S (2013) Management of Non Variceal Upper Gastrointestinal Bleed. J Gastroint Dig Syst S3: 004. doi:10.4172/2161-069X.S3-004

Copyright: © 2013 Safwat S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Keywords: GI Bleeds; Variceal; Haematemesis; Comorbidities

Scores to Identify High Risk and Low Risk PatientsThe various scoring systems aim to identify significant bleeds and

patients with comorbidities that would worsen the outcome [1-7] (Table 1).

Rockall ScoreThe two scoring systems are useful in identifying the high and

low risk patients, but clinical judgment is superior [8-10]. It is also worth noting that GI bleeding in inpatients has a three folds increase in mortality [11-12]. So in general a patient who has a witnessed haematemesis or melena in hospital has a significant bleed and requires special attention. A systolic blood pressure below 100 a heart rate above 100 per minute, Haemoglobin level below 10 gm/dl and a high urea in a bleeding patient should alert you that an early endoscopic intervention is warranted (Table 2).

Preparing the Patient for Endoscopic InterventionResuscitation of the haemodynamically unstable patient with

gastrointestinal bleeding is vital, particularly if they are elderly or have comorbidities. There are certain issues with bleeders that should be highlighted:

1. Avoid overzealous filling of your patient. As any good plumberwould tell you, the first rule of good plumbing; before fixingthe leak you need to switch off the main water supply. Aim tokeep the systolic BP at 100 mmHg and Hemoglobin at 7 gm/dl [13]. These patients are better treated in specialized or highdependency units, particularly the vulnerable elderly andpatients with co-morbidities. If variceal bleed is suspectedPortal pressure (Hepatic venous pressure gradient) should bereduced by the use of Terlipressin or somatostatin [14,15].

2. Correct significant clotting disorders.

3. Decide on the place for endoscopy and the support required:either A&E, operating theatre, endoscopy unit or ITU. Thisdepends on what is available in your hospital, the risk ofaspiration and the availability of specialist endoscopy nurses.

4. Patients with suspected variceal bleed benefit from prophylacticantibiotics as it improves mortality [16-18].

5. Intravenous proton pump inhibitor: This should be given inserious GI bleeds; 80 mg IV pantoprazole stat followed by 8 mgper hour for 72 hours or40 mg qds. There is controversy about

Glasgow-Blatchford ScoreAdmission risk marker Score component value

Blood Urea≥ 6.5 <8.0 2≥ 8.0 <10.0 3≥ 10.0 <25.0 4

≥ 25 6Haemoglobin (g/L) for men

≥ 12.0 <13.0 1≥ 10.0 <12.0 3

<10.0 6Haemoglobin (g/L) for women

≥ 10.0 <12.0 1<10.0 6

Systolic blood pressure (mm Hg)100-109 190-99 2<90 3

Other markersPulse ≥ 100 (per min) 1

Presentation with melaena 1Presentation with syncope 2

Hepatic disease 2Cardiac failure 2

A score of 6 or more is associated with a greater than 50% need for intervention, while a score of zero means that hospitalization is not required [7].

Table 1: Glasgow-Blatchford Score.

Variable Score 0 Score 1 Score 2 Score 3Age <60 60- 79 >80Shock No shock Pulse >100 SBP <100

BP >100 Systolic

Co-morbidity Nil major CHF, IHD,

major morbidity

Renal failure, liver failure, metastatic cancer

Diagnosis Mallory-Weiss All other diagnoses

GI malignancy

Evidence of

bleeding

None Blood, adherent clot, spurting vessel

8 points put patient in high risk, while 2 points or less is low risk.Table 2: Rockall score.

Journal

of G

astro

intestinal & DigestiveSystem

ISSN: 2161-069X

Journal of Gastrointestinal & Digestive System

Citation: Safwat S (2013) Management of Non Variceal Upper Gastrointestinal Bleed. J Gastroint Dig Syst S3: 004. doi:10.4172/2161-069X.S3-004

Page 2 of 3

J Gastroint Dig Syst Gastrointestinal Disease Treatment ISSN: 2161-069X JGDS, an open access journal

the use of ppi prior to endoscopic therapy of non variceal GI bleed. Although it does not improve mortality, it is associated with significant down staging of endoscopic lesions [19,20].

6. IV Erythromycin prior to endoscopy improves visibility during endoscopy [21].

Endoscopic Management

AB

C

Figure 2: Signs of recent hemorrhagea. Forrest II a (Visible vessel) = Rebleeding Rate 40-50%b. Forrest II b (Adherent clot) = Re-bleeding rate 30%c. Forrest II c (Haematin on ulcer base) = Re-bleeding rate 10%

Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered ulcer base) = re-bleeding rate 5%

Figure 3: Lesions without active bleeding.

A B

Figure 1: Acute hemorrhage.a. Forrest I a (Spurting hemorrhage) = Risk of re-bleeding 100%.b. Forrest I b (Oozing hemorrhage) = Risk of re-bleeding 55%.

Bleeding peptic ulcer

Two sites in the upper GI tract are associated with significant bleeds due to anatomical proximity to arteries. Posterior wall of first part of duodenum from gastrodudenal artery and proximal lesser curve of stomach from left Gastric artery.

There are several endoscopic features that give indication to the seriousness of the bleed and the risk of re-bleeding. The Forrest classification describes various degrees of bleeding from ulcers and the re-bleeding risk associated. Other factors associated with failure of haemostasis are ulcer size, presence of shock at presentation and previous ulcer bleeding.

Forrest classification [22]

(Figure 1) (Figure 2) (Figure 3)

Strategies for a successful endoscopic haemostasis

Keeping the systolic blood pressure at around 100 mmHg and restricting the use of blood transfusions unless the Haemoglobin is 7 gms or less gives the endoscopist an advantage with a less bloody field, allows for better visualization of the ulcer field and improves survival [23].

Three modalities are available to control ulcer bleeding; adrenaline (1:10000) injection, Heat probe and clips. Adrenaline injection, although not proven to improve survival as a single modality, it is a very useful temporary method to control the bleeding by both its tamponade effect and vasoconstriction [24]. If a visible vessel is seen it can be tackled by either heat probe or clip without prior adrenaline injection. When a clot is seen, injecting adrenalin at the base of the ulcer, around the clot loosens it, and it can be washed off by water spray. If the clot does not wash away, you may shave it off using a snare. Once the clot is dislodged any visible vessel should be dealt with either with heat probe or clip. Attempts should be repeated till you can see a clean ulcer base.

Surgical treatment would be required if endoscopic intervention fails to stop the bleeding. Information regarding the site of bleeding

A B`

E`

C

D F

Mallory Weiss tear Mallory-Weiss with bleeding

GIST with ulceration

Figure 4: a. Oesophageal Varicesb. Mallory-Weiss Tear: History is usually of severe retching followed by red fresh blood haematemesis. Bleeding may be quiet significant particularly in anti-coagulated patients.c. Ulcer within Barretts and a visible vesseld. Angiodysplasia duodenume. Gastrointestinal Stromal Tumour (GIST): This usually requires surgical excision.f. Malignancy: Gastric Lymphoma

Citation: Safwat S (2013) Management of Non Variceal Upper Gastrointestinal Bleed. J Gastroint Dig Syst S3: 004. doi:10.4172/2161-069X.S3-004

Page 3 of 3

J Gastroint Dig Syst Gastrointestinal Disease Treatment ISSN: 2161-069X JGDS, an open access journal

is important to be passed on to the surgeon. In case of failure to identify the bleeding point triple phase CT angiography is required and interventional angiography can be used to control the bleeding.

After successful treatment of a bleeding peptic ulcer, gastric ulcer patients should be re-scoped in 6 weeks to ensure healing. Duodenal ulcer patients do not require re-scoping but they would benefit from H pylori eradication.

Other Causes of Upper GI Bleed

(Figure 4 (a-f))

ConclusionManagement of the upper GI bleed should not be perplexing as

long as you are well prepared. As Billy Connelly said ‘There is no such thing as bad weather, only bad clothes’.

References

1. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, et al. (2004) Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 40: 652-659.

2. Chalasani N, Kahi C, Francois F, Pinto A, Marathe A, et al. (2003) Improved patient survival after acute variceal bleeding: a multicenter, cohort study. Am J Gastroenterol 98: 653-659.

3. Thomopoulos K, Theocharis G, Mimidis K, Lampropoulou-Karatza Ch, Alexandridis E, et al. (2006) Improved survival of patients presenting with acute variceal bleeding. Prognostic indicators of short- and long-term mortality. Dig Liver Dis 38: 899-904.

4. Crooks C, Card T, West J (2011) Reductions in 28-day mortality following hospital admission for upper gastrointestinal hemorrhage. Gastroenterology 141: 62-70.

5. Lim LG, Ho KY, Chan YH, Teoh PL, Khor CJ, et al. (2011) Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Endoscopy 43: 300-306.

6. Hsu YC, Chung CS, Tseng CH, Lin TL, Liou JM, et al. (2009) Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol 24: 1294-1299.

7. Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, et al. (2009) Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. The Lancet 373: 42-47.

8. Rockall TA, Logan RF, Devlin HB, Northfield TC (1996) Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38: 316-321.

9. Vreeburg EM, Terwee CB, Snel P, Rauws EA, Bartelsman JF, et al. (1999) Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut 44: 331-335.

10. Farooq FT, Lee MH, Das A, Dixit R, Wong RC (2012) Clinical triage decision vs risk scores in predicting the need for endotherapy in upper gastrointestinal bleeding. Am J Emerg Med 30: 129-134.

11. Müller T, Barkun AN, Martel M (2009) Non-variceal upper GI bleeding in patients already hospitalized for another condition. Am J Gastroenterol 104: 330-339.

12. Lanas A, Aabakken L, Fonseca J, Mungan ZA, Papatheodoridis GV, et al. (2011) Clinical predictors of poor outcomes among patients with nonvariceal upper gastrointestinal bleeding in Europe. Aliment Pharmacol Ther 33: 1225-1233.

13. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, et al. (2013) Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368: 11-21.

14. Abraldes JG, Villanueva C, Bañares R, Aracil C, Catalina MV, et al. (2008) Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 48: 229-236.

15. Ioannou G, Doust J, Rockey DC (2003) Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 1: CD002147.

16. Bernard B, Grangé JD, Khac EN, Amiot X, Opolon P, et al. (1999) Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 29: 1655-1661.

17. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M (2010) Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev : CD002907.

18. Augustin S, Altamirano J, González A, Dot J, Abu-Suboh M, et al. (2011) Effectiveness of combined pharmacologic and ligation therapy in high-risk patients with acute esophageal variceal bleeding. Am J Gastroenterol 106: 1787-1795.

19. Hsu YC, Perng CL, Yang TH, Wang CS, Hsu WL, et al. (2010) A randomized controlled trial comparing two different dosages of infusional pantoprazole in peptic ulcer bleeding. Br J Clin Pharmacol 69: 245-251.

20. Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, et al. (2010) Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 7: CD005415.

21. Bai Y, Guo JF, Li ZS (2011) Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding. Aliment Pharmacol Ther 34: 166-171.

22. Guglielmi A, Ruzzenente A, Sandri M, Kind R, Lombardo F, et al. (2002) Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer. Endoscopy 34: 778-786.

23. Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, et al. (2013) Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368: 11-21.

24. Vergara M, Calvet X, Gisbert JP (2007) Epinephrine injection versus epinephrine injection and a second endoscopic method in high risk bleeding ulcers. Cochrane Database Syst Rev : CD005584.

This article was originally published in a special issue, Gastrointestinal Disease Treatment handled by Editor(s). Dr. Tauseef Ali, University of Oklahoma Health Sciences Center, USA