Upper Gastrointestinal Bleeding – what to do…

Dr Chris RoseveareConsultant PhysicianSouthampton University Hospitals NHS Trust

What to do…. Resuscitate Endoscope If all else fails – call a surgeon

Introduction 7-8% mortality overall 26-44% mortality if already hospitalised

Poor prognostic factors… Older age

>60 – OR: 1.8-3 >75 – OR: 4-12

Co-morbidities Cardiac failure - OR: 1.8 Malignancy - OR: 3.8

Initial shock - OR: 3.8 Haematemesis at presentation - OR: 2

Acute UGI Bleeding unitPatient Group(n=900)

SMR 95% conf interval

All 0.63 0.48-0.78

Low risk(Rockall 0-3)

0.35 0.00-1.04

Medium risk(Rockall 4-6)

0.56 0.34-0.78

High risk(Rockall >7)

0.7 0.49-0.91

Sanders et al. Eur J Gast Hep 2004, 16(5) 487-94

Is the patient shocked?Class I Class II Class II I Class IV

Vol loss (ml)

<750 750-1500 1500-2000 >2000

Vol loss (%)

0-15 15-30 30-40 >40

Systolic Normal Normal Low V LowDiastolic Normal Raised Low V LowPulse Slight

tachy100-120 120 thready >120, v

threadyResp rate Normal Normal >20 >20Mental state

Alert Anxious / aggressive

Drowsy Confused / unconscious

What size cannula?

Jean Louis Poiseuille (1799 - 1869)

What size cannula?

Flow Rates through Cannulae (ml/min)

Colour Gauge Flow rate (ml/min)

Pink 20 40

Green 18 75

Grey 16 150

Orange 14 300

Triple lumen CVP line

16 50

What size cannula?

Consider CVP line if: Large volume bleed Coexistent renal / cardiac failure Persistent hypotension / tachycardia Suspected / proven varices

Resuscitation

What fluid replacement? Blood if >30% volume loss

?O-negative ?Group specific ?Cross-matched

Crystalloid or colloid? No comparative studies in UGIB Probably makes no difference

Could it be varices? Any upper GI bleed with:

Previous history of varices / variceal bleed Clinical evidence of chronic liver disease or

portal hypertension

NB: most ‘alcoholics’ with GI bleeds do not have chronic liver disease (or varices)

Could it be varices? Yes……….

Consider airway protection

High risk of aspiration with high mortality

Could it be varices? Yes……….

Reconsider CVP line (if not already)

Avoid over-transfusion

Could it be varices? Yes……….

Correct clotting and platelets

Could it be varices? Yes……….

Commence Terlipressin 2mg 6 hourly

Superior to endoscopic sclerotherapy inBleeding control (Cochrane 2002)

20% reduction in 5 day bleeding control When combined with endoscopic therapy

Could it be varices? Yes……….

Endoscopy at earliest opportunity

It’s not always varices

Could it be varices? Yes……….

Endoscopy at earliest opportunity

Enables endoscopic therapy

Could it be varices? Yes……….

Consider Sengstaken-Blakemore tube

Reconsider airway protection

May be safer to transfuse and await endoscopist

What’s the diagnosis?

An 80 year-old woman is brought to hospital having collapsed in her home. On arrival of the ambulance she was hypotensive, grey and sweaty. The ambulance crew reported ‘coffee ground vomit’ while en-route.

What’s the diagnosis?

What is ‘coffee grounds’?

A B

C D

What is ‘coffee grounds’?

Think…. Is the degree of haemodynamic

compromise consistent with volume of reported blood loss?

Beware a shocked patient with ‘dark’ vomit look for an alternative explanation for

hypotension.

Why endoscope? Diagnose Treat Risk stratification

Endoscopic diagnosis…Diagnosis Approx %Peptic Ulcer 44Oesophagitis 28Gastritis / erosions 26Duodenitis / erosions 15Varices 13Mallory-weiss Tear 5Malignancy 5Vascular Malformations 3

Why endoscope a patient? Therapeutic

Stop bleeding

Why endoscope a patient? Therapeutic

prevent rebleed

Why endoscope a patient? Therapeutic

prevent rebleed

Risk Stratification Calculation of full Rockall Score

Rockall Score0 1 2 3

Age <60 60-79 >=80

Shock Systolic >100Pulse <100

Systolic >100Pulse >100

Systolic <100

Comorbidity None Heart FailureIHDMajor Comorb

Renal failureLiver FailureDiss Malig.

Diagnosis M-W Tear orNo lesion

All other diagnoses

Upper GI malignancy

Bleeding stigmata

None or dark spot only

Other stigmata

Rockall Score

0

5

1015

20

25

30

35

40

45

0 1 2 3 4 5 6 7 8+

Rebleed

Mortality

Score

Per cent

When to endoscope? Too soon?

Inadequate resuscitation: higher risk Poor views (blood in the way) Aspiration (stomach full of blood)

When to endoscope? Too late?

Ongoing bleeding Rebleeding Delay to surgery

When to endoscope? ASAP if:

Evidence of ongoing bleeding Suspected varices Suspected early rebleed

Otherwise within 12 hrs is usually OK

What about IV PPI? Clots more stable when pH >4 Clot lysis occurs when pH <4

What about IV PPI? Omeprazole 80mg IV bolus followed by 8mg/hour

infusion for 72 hours reduced early rebleed rate (5 vs 24 rebleeds with placebo, p<0.001) In patients with endoscopically proven

peptic ulcer with st igmata of haemorrhage

Lau et al. NEJM 2000;343:310-6

What about IV PPI?

Limited evidence for ‘empirical’ use of IV PPI

prior to endoscopicdiagnosis in unselected patients

What if the patient rebleeds? Repeat endoscopy Radiological embolisation Surgery

Repeat Endoscopy No difference in bleeding control between

surgery and second endoscopic treatment 30 day mortality and transfusion requirements

similar More complications in group randomised to

surgery

Lau et al N Engl J Med 1999;340:751-756

Radiological Embolisation Equally effective to surgery as

measured by: Rates of re-bleeding Rates of mortality

Ripoll et al J Vasc Interv Radiol 2004; 15:447-450

What about surgery? >65 with one ‘rebleed’ or > 4 units blood

required for fluid resuscitation <65 with 2 rebleeds or >8 units blood

required for fluid resuscitation

What about Surgery? Dependent on:

Type of lesion Site of lesion Co-morbidities Likelihood of continued bleeding

Summary Resuscitate adequately Exclude varices (and non-GI source of

shock) Endoscopy within 12 hours if non-

variceal Intravenous PPI infusion if peptic ulcer

bleed with stigmata of haemorrhage