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Information ⬇

Author(s): Simon Anderson and Udi Shmueli

  • This usually presents with haematemesis or melaena (Box 73.1), but should be considered in any patient with unexplained hypotension or syncope, or decompensated chronic liver disease.
  • Causes of upper gastrointestinal (GI) bleeding are given in Table 73.1. About 90% of non-variceal bleeds and 50% of variceal bleeds stop spontaneously. Mortality is around 7–10% in patients with non-variceal bleeds, and 30% in those with variceal bleeds. Almost all deaths occur in patients >65 years and those with major comorbidities, most often from multi-organ failure secondary to hypovolaemia/hypotension.
  • In patients with severe upper GI bleeding, a good outcome requires vigorous resuscitation, and close collaboration with medical, endoscopic, radiological and surgical teams: it is important to involve these specialists as early as possible to discuss the management plan.

Priorities ⬆ ⬇

  1. Make a rapid clinical assessment, to include an estimate of the volume of blood lost (Table 73.2). Put in a large-bore IV cannula (e.g. green or grey Venflon), and take 20 mL of blood for urgent investigations (Table 73.3). Initial fluid resuscitation should be with IV crystalloid. Give blood when available if the patient is shocked, or actively bleeding with a haemoglobin of <90g/L.

    The Blatchford score (Table 73.4) is a screening tool to assess the probability that endoscopic intervention or blood transfusion will be needed, and is helpful when discussing the patient's management with colleagues.

  2. If there is hypovolaemic shock (systolic blood pressure ≤90 mmHg, pulse ≥100/min, cold extremities):
    • Give oxygen 60–100% and attach an ECG monitor.
    • Obtain help:
      • Inform gastroenterology/surgical colleagues, and contact the on-call endoscopy service, to arrange urgent endoscopy.
      • Put out a major haemorrhage call.
      • Call the on-call anaesthetist for endotracheal intubation if there is respiratory failure or a reduced level of consciousness (e.g. Glasgow coma scale score <9).
    • Transfuse blood products within the pre-assembled packs. If systolic blood pressure remains <100 mmHg, use uncrossmatched O Rhesus negative blood (Rhesus positive blood is acceptable for males and post-menopausal females). Start transfusing crossmatched blood as soon as it is available, via a second IV cannula. Use a blood warmer if infusing at >50 mL/kg/hour.
    • Correct clotting abnormalities (see below).
    • Insert a urinary catheter to monitor the urine output (aim for urine output of 0.5 mL/kg/hour).
  3. Correct clotting abnormalities
    • If the fibrinogen level is <1.5g/L, or the prothrombin time (or international normalized ratio, INR) is >1.5×control, give 2 units of fresh frozen plasma.
    • If the patient is taking warfarin and is actively bleeding, give vitamin K, 5–10 mg by slow IV injection, and consider giving prothrombin complex concentrate: discuss with a haematologist (see Chapter 103).
    • If the patient is taking a direct-acting oral anticoagulant (e.g. dabigatran, rivaroxaban), discuss management with a haematologist (see Chapter 103).
    • If the platelet count is <50×109/L, and the patient is actively bleeding, give platelet concentrate: discuss with a haematologist.
  4. If you suspect bleeding oesophageal or gastric varices (because of a past history of variceal bleeding or chronic liver disease):
    • Give terlipressin 2 mg IV followed by 1–2 mg 4–6 hourly until bleeding is controlled, for up to 5 days.
    • Give IV antibiotic (e.g. coamoxiclav 1.2 g 8-hourly IV or tazocin 4.5g 8-hourly IV), to prevent bacterial infection (including spontaneous bacterial peritonitis, Chapter 24), which is a common complication.
    • Contact the endoscopy service for urgent endoscopy, to define the source of bleeding and for therapeutic endoscopy (banding of bleeding varices).
    • If bleeding continues, or there is any impairment in conscious level, contact an anaesthetist to discuss endotracheal intubation.
    • If there is continued variceal bleeding (and the airway is protected by endotracheal intubation), a Sengstaken-Blakemore tube (Chapter 125) can be inserted by an experienced operator.
    • Other supportive measures for patients with decompensated chronic liver disease are discussed in Chapter 77.
  5. In patients without shock but with evidence of significant blood loss (e.g. syncope in association with bleeding; clinical signs of blood loss >750 mL) or haemoglobin <100g/L:
    • Start an infusion of crystalloid to maintain systolic blood pressure >100 mmHg.
    • Transfuse blood if the initial haemoglobin is <70g/L.
    • Correct clotting abnormalities (see above).
    • Contact the on-call endoscopy service to arrange endoscopy within 24hours.

Further Management ⬆ ⬇

Outline

Blood Transfusion!!navigator!!

Once the volume deficit has been corrected, recheck the haemoglobin and transfuse blood if this is 70g/L or below.

Endoscopy!!navigator!!

  • Urgent endoscopy is needed for patients with shock on admission (but not before adequate resuscitation), with known varices or signs of chronic liver disease, or evidence of continued bleeding.
  • Other patients should have endoscopy within 24hours of admission (with the exception of those with a Blatchford score of zero, who can be considered for discharge with outpatient endoscopy). They can be allowed to eat, but must be nil by mouth for >4hours prior to endoscopy.

Drug Therapy!!navigator!!

  • Stop nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Anticoagulant and antiplatelet therapy should be stopped/reversed, if the benefits of doing so outweigh the risks: for patients with a mechanical prosthetic heart valve, recent acute coronary syndrome or coronary stents, discuss this with a cardiologist. See Chapter 103.
  • There is no evidence that starting a proton pump inhibitor (PPI) before endoscopy alters outcome. Treatment with a PPI makes testing for Helicobacter pylori unreliable.
  • There is no firm evidence to support antifibrinolytic therapy (tranexamic acid) before or after endoscopy.
  • The HALT-IT trial is assessing whether early administration of tranexamic acid can reduce the in-hospital mortality of upper GI bleeding, and improve outcomes. The trial aims to complete recruitment in 2017.

Management after Endoscopy!!navigator!!

  • Calculate the Rockall score (Table 73.5). Those with a score ≤2 can be discharged (predicted mortality <1%). Those with a score ≥3 should remain in hospital for close observation.
  • Further management is determined by the endoscopic diagnosis, and should be discussed with a gastroenterologist.

Peptic Ulcer!!navigator!!

  • Patients with low-risk peptic ulcer bleeding based on clinical and endoscopic criteria (e.g. clean ulcer base) can be discharged on the same day as endoscopy.
  • Most patients with high-risk peptic ulcer bleeding based on clinical and endoscopic criteria (e.g. stigmata of recent haemorrhage) should remain hospitalized for at least 72 h.
  • Start a proton pump inhibitor (PPI). If the patient is stable and able to tolerate oral medication, this can be administered by mouth (e.g. omeprazole 40 mg PO 12-hourly). If the patient is at high risk of further bleeding (high Rockall score) or unable to tolerate oral medication, give a bolus of omeprazole (or pantoprazole) 80 mg IV followed by an infusion of 8 mg/hour for 72 h.
  • Rebleeding after an initial endoscopy requires either a repeat endoscopy or referral to interventional radiology, depending on the initial findings at endoscopy. If interventional radiology is not promptly available, refer for surgery.
  • Full dose PPIs should be given for at least four weeks.
  • Most patients with gastric ulcers should have a repeat endoscopy at 6–8 weeks to confirm healing and exclude malignancy.
  • If Helicobacter pylori positive, start eradication treatment according to local protocols. Most ulcers not due to NSAIDs or aspirin are associated with H. pylori infection. As the Clotest taken at endoscopy may be falsely negative when taken at the time of an acute bleed, a high index of suspicion should be kept and a urease breath test (off PPIs) should be ordered after the acute event when appropriate. Gastric biopsies taken for histology at the time of the initial endoscopy, can also improve the detection rate.
  • Anticoagulant and antiplatelet therapy: NSAIDs should be stopped; low-dose aspirin, if needed for secondary prevention of vascular events or coronary stent thrombosis, can be continued with concomitant PPI therapy. Other antiplatelet agents (e.g. clopidogrel) should be stopped temporarily and timing of restarting discussed with the appropriate specialist (cardiologist or stroke physician).

Erosive Gastritis!!navigator!!

There are two groups of patients:

  • Previously well patients in whom erosive gastritis is related to aspirin, NSAIDs or alcohol. Bleeding usually stops when these agents are withdrawn and no specific treatment is needed. A short course of a PPI can be given to limit concomitant damage from acid exposure. H. pylori should be treated if present.
  • In critically ill patients with stress ulceration, in whom the mortality is high, correct clotting abnormalities and give a PPI. Sucralfate is also an option.

Oesophagitis and Oesophageal Ulcer!!navigator!!

Give a PPI for 4 weeks, followed by a further 4–8 weeks treatment if not fully healed.

Oesophageal and Gastric Varices!!navigator!!

  • Variceal bleeding stops spontaneously in 50% of patients. The risk of further bleeding can be substantially reduced by follow-up endoscopic therapy to obliterate residual varices, and administration of a non-selective beta blocker (e.g. propranolol or carvedilol).
  • Discuss management of the varices and the underlying cause of portal hypertension with a gastroenterologist or hepatologist.

Mallory-Weiss Tear!!navigator!!

  • Bleeding usually stops spontaneously and rebleeding is rare.
  • If bleeding continues, the options are repeat endoscopy with a view to endotherapy (argon-plasma coagulation, application of haemostasis clip), tamponade using a Sengstaken-Blakemore tube, or interventional radiology for embolization.

Negative Endoscopy!!navigator!!

  • In 15–20% of patients, the first endoscopy does not reveal a source of bleeding. Discuss repeating the endoscopy, especially if blood or food obscured the views obtained, or the patient has chronic liver disease (as varices which have recently bled may not be visible).
  • Patients who presented with melaena alone, should be investigated for a small bowel or proximal colonic source of bleeding (Chapter 74, Table 74.1). A normal blood urea suggests a colonic cause of melaena, except in patients with chronic liver disease (in whom urea levels are often low).
  • CT angiography can be useful after two negative endoscopies, but only if performed when the patient is actively bleeding.

Further Reading ⬆

Gerson LB, Fidler JL, Cave DR, et al. (2015) American College of Gastroenterology Clinical Guideline: Diagnosis and management of small bowel bleeding. Am J Gastroenterol 110, 1265–1287.

National Institute for Health and Care Excellence (2015) Blood transfusion. NICE guideline (NG24). https://www.nice.org.uk/guidance/ng24.

National Institute for Health and Care Excellence (2016) Acute upper gastrointestinal bleeding in over 16s: management. Clinical guideline (CG141). https://www.nice.org.uk/guidance/cg141?unlid = 122385053201610212730.

Tripathi DJ, Stanley AJ, Hayes PC (2015) UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 1–25. DOI: 10.1136/gutjnl-2015-309262.