Upper gastrointestinal bleeds (UGI) bleeds

Aetiology of upper GI (UGI) bleeds

• Peptic ulcer disease –  oesophageal, gastric or duodenal ulcers
  • Prevalence 4% of the population
  • Due to H. pylori, NSAID use, alcohol, steroid use, Zollinger-Ellison syndrome (gastrin-secreting tumour causing multiple ulcers)
• Oesophagitis and gastroduodenal erosions (15%)
  • Due to aspirin, other NSAIDs, steroids
• Oesophageal varices
  • Due to portal hypertension, usually associated with chronic liver disease
• Portal hypertensive gastropathy
• Mallory-Weiss tears
  • Secondary to prolonged vomiting
• Dieulafoy’s lesion
  • Tortuous arteriole usually upper part of lesser curve, bleeding occurs through a tiny defect.
• GORD
• Upper GI malignancy
• Vascular malformations
• Aorto-enteric fistula (commonest at approx 5 years post-surgery. Approx 2% risk)

History in upper GI (UGI) bleeds

• History of presenting complaint
  • Haematemesis – can be bright red OR coffee-ground
  • Melaena – distinctive smell, tar-like
    • Volume of blood loss in either case
  • Dyspesia
  • Dizziness
  • Chest pain
  • Prolonged vomiting/retching
  • Constitutional symptoms
• Past medical history
  • Previous GI bleed
  • Known PUD/varices
  • Malignancy
  • Liver disease
  • Known cardiovascular/respiratory disease (fitness to undergo sedation and/or intubation for endoscopy)
• Medications
  • NSAIDs
  • Steroids
  • Anticoagulants
• Allergies
• Social history
  • Alcohol consumption

Video explaining Upper GI Bleeds

Examination of upper GI (UGI) bleeds

• Signs of chronic liver disease
• DRE for melaena
• Signs of shock
  • Tachycardia, hypotension, altered conscious level, postural BP (often not appropriate in acute setting)
• Encephalopathy

Initial management of acute upper GI (UGI) bleeds

– see http://www.nice.org.uk/guidance/cg141/chapter/1-recommendations for further details

• Resuscitation
  • A – manage airway and consider need for intubation/airway adjunct or suctioning
  • B – give oxygen to maintain sats > 96%
  • C –
    • BP, HR
    • Large-bore IV access x 2
    • VBG to assess Hb, acidosis, lactate
    • Send lab bloods for FBC, U+Es, clotting, X-match (2-4 units usually)
    • IV fluid resuscitation (crystalloid is fine acutely)
  • D – AVPU, check glucose level
  • E – ?peritonitic abdomen
• Imaging
  • Erect CXR to look for gas under diaphgragm
• Catheter insertion for accurate fluid balance monitoring
• Transfusion
  • Transfuse with x-matched (or O-neg or type-specific blood if very urgent) blood if haemodynamically unstable
  • Current guidelines suggest transfusing if Hb < 7 for patients with cirrhosis
  • If massive blood loss occurs then follow local protocols for transfusing platelets and clotting factors along with blood.
  • Give prothrombin concentrate complex to patients on warfarin who are actively bleeding
• Proton-pump inhibitors
  • Current NICE guidance is NOT to give acid-suppression (PPIs, H2-RA) to patients with suspected non-variceal bleeds prior to endoscopy).
  • If evidence of recent haemorrhage then IV or oral PPI is given post-endoscopy
  • In practice however, this is still commonly given prior to endoscopy
• Prokinetic
  • Metoclopramide 10mg IV can be given to empty the stomach contents to allow better views at endoscopy
• Variceal bleeds
  • Treat as above
  • Give broad-spectrum antibiotics i.e. IV Tazocin 4.5g
  • Give IV Terlipressin 2g (unless peripheral vascular disease)
• Endoscopy
  • Scoring system (see below)
  • Offer endoscopy to unstable patients with severe bleeding immediately after resuscitation
  • Offer endoscopy to all other patients within 24 hours
  • Management of non-variceal bleeding
    • Clips +/- adrenaline
    • Thermal coagulation with adrenaline
    • Fibrin/thrombin with adrenaline
  • Management of variceal bleeding
    • Band ligation for oesophageal varices
    • Injection of N-butyl-2-cyanoacrylate for gastric varices
    • Consider TIPSS procedure if the above methods do not control the bleeding

Further management of acute upper GI (UGI) bleeds

• Sengstaken-Blakemore tube
  • A tube inserted into the stomach with gastric and oesophageal balloons – ONLY inflate the gastric balloon
  • Can only be used in intubated patients with varices
  • Used as a bridge for definitive therapy – usually either endoscopy or TIPSS
• Surgical intervention
  • Perforated viscus

Scoring systems for upper GI (UGI) bleeds

• Rockall
  • Prognosticates
  • Age, Shock, co-morbidities
    • Diagnosis and stigmata after endoscopy
  • Scores below 2 have a very low mortality
  • Scores 8 or higher have a mortality of 40%+

• Blatchford-Glasgow
  • Risk stratify – predicts the need for hospital-based intervention
    • Urea, Hb, Systolic BP
    • Other: pulse, melaena, syncope, hepatic disease, cardiac failure
  • Use acutely but not as good as Rockall in predicting overall mortality
  • Score 0 = home
  • Score >0 = endoscopy
  • Score >5 (6 and up) = same day endoscopy

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