Upper GI Bleeding
Dr.Vimalan Ambikaipaker
Gastro Advanced trainee
JHH
“blood and guts””
Upper GIH
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Potential life threatening problem
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Upper GIT is 4times more common than Lower GIT
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Most common course – peptic ulcer
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80% stop bleeding
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Increasing age and co-morbidity increases mortality
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Important to indentify patients with low probability of rebleeding from patients with a high probability of rebleeding.
Upper GI anatomy
Lower GI anatomy
Aetiology
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Peptic ulcer disease 35-50%
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Duodenal ulcers 25%
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Gastric Ulcer 20%
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Gastroduodenal erosions 8-15%
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esophagitis 5-15%
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Esophageal varices 5-10%
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Malignancy 1%
Aetiology - rare
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Dieulafoy’s lesions
Angiodysplasia
Haemobilia
Pancreatic pseudocyst and pseudo aneursym
Bleeding diathesis
Ehlers-danlos syndrome
Gastric antral vascular ectasia
Rendu-osler-weber-syndrome
Pseudoxanthoma elasticum
NVUGIB Consensus
Guidelines
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A - Resuscitation, risk assessment and pre-endoscopy
management
B - Endoscopic management
C – Pharmacological management
D – Non-endoscopic, non- meds in hospital treatment
E – Medication review, ASA, Clopidrogel, warfarin dabigratan
(Pradaxa) and NSAIDS.
F – Discharge planning and Communication to GP
G – Need for gastro liaison service to be involved
A - Resuscitation, risk assessment
and pre-endoscopy management
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History taking
>vomiting large amounts of red blood (active bleeding)
>Coffee-ground vomitus (older-non active bleeding)
> History melaena (black, tarry, smelly, difficulty to flush and
iron tablets)
>Haematochezia in rectum
? Bowel obstruction
Weight lost, diffuse or localised abdominal, retching
History
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Co- morbidity and risk factors
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GERD, Peptic ulcers ,alcohol intake ,bleeding before
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Liver cirrhosis
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Liver malignancy
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Haematological disease – Low platelets, bleeding diathesis
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Abdominal Aneurysm
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Lung disease ,OSA, sedation issues
Medications
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Aspirin
Clexane
Clopidrogel
Dabigratan (pradaxa)
Warfarin
NSAIDS
Steroids
Iron tablets and bismuth
Sedation issues – opiods,Marijuana,Methadone
Examination
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Vital signs
Signs of chronic liver disease
Decompensated liver disease
Acute abdomen
Encephalopathy
PR rectal examination
A - Resuscitation, risk assessment
and pre-endoscopy management
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ABC
2 IV lines
FBC,U/E, LFT, Coags, group and save/ crossmatch,ECG
Need for FFP, Prothrombin X and platelets and correct
coagulopathy(<2.5)
IV fluid resuscitation
Blood transfusion (Hb<70)
Imaging CXR and AXR
IV PPI Infusion and consider OCTREOTIDE infusion if suspect
varices bleed.
Reduce risk of aspiration , IV maxolon or IV erythromycin)
Aims- BP >100mmHg,HR<100bpm,HCT>24%,Platelets>50
Correct INR,? ICU/Haematologist
Urgent endoscopy
Contact gastroenterologist on call (Urgency made
clearly to the consultant)
A - Resuscitation, risk assessment
and pre-endoscopy management
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PPI Infusion
Before endoscopy, accelerate the resolution of endoscopic
stigmata of bleeding ulcers and reduce the need for
endoscopic therapy but should not delay endoscopy.
Does not result in improved clinical outcomes such as
decrease transfusions, rebleeding, surgery or death.
PPI initiated after endoscopic diagnosis of peptic ulcer bleed
significantly reduces rebleeding and surgery rates
Effects are more pronounced in Asian compared to with nonAsian populations
Continue IV infusion for 3days
Octreotide infusion
Reduces rebleeding rates similar to endoscopic sclerotherapy
Continue infusion for 5days
Risk assessment
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Rockall Score
Factors – Age,shock,C0-mobidity,Diagnosis
Major stigmata – blood in GI tract, adherent clot, visible and spurting
vessel
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rebleeding
Longer stay in hospital
Rescoping
But always use clinical judgement
How to provoke homicidal rage
in the Gastroenterologist
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Tell them the patient is “haemodynamically stable”
Don’t tell them anything but fast the patient “just in
case”
Insert a venous cannula of 24 gauge or less
Do not cross match
Start a PPI infusion without any plans for an
endoscopy
Perform Faecal Occult Blood test
Don’t call them early
Post endoscopy – no blood or stool chart monitoring
Fail to identify rebleeding in post endoscopy patients
God gave you hands – use the one finger though!!!
What to the gastroenterologist
need to know
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Accurate history
Co-morbidity
Medication and sedation issues
Physical examination and PR findings
Resuscitation Plan and monitoring plan
Retrieval plan
Discuss time for endoscopy or the need to be done
in theatre
Booking of endoscopy unit and theatre nurse in
charge is aware. Red slip!! and consent
Gastroenterologist needs to know early
B- Endoscopic management
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Early endoscopy , within 24hrs
More urgent (vomiting bright red blood or haematochezia
Endoscopic hemostatic tx is not indicated for patients with
low-risk stigmata (clean based ulcer, or a non-protuberant
pigmented dot in an ulcer bed)
Finding of clot in ulcer bed warrants target irrigation an
attempt dislodgement and with an appropriate treatment of
underlying lesion (adrenaline with APC) or PPI might be
enough.
Endoscopic hemostatic tx is indicated for patients with highrisk stigmata.
Combination – epinephrine with either (APC, Clip or sclerosant
injection)
If rebleed – need second look
Need for surgical team involvement
Esophagus
Esophagus
Stomach
Duodenum
Video clip
Endoscopic haemostatic
Treatment
Esophageal varices
Stomach Varices
Video clip
Video clip
D- non-endoscopic, non meds
in hospital treatment
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Rockall score <3 with low risk of bleeding or death can be
considered for early discharge.
Full Rockwall score >3 indicates patients needs further close
observation as an in patient. Careful monitoring needed post
endoscopy
Need for re-endoscopy
If patient is at low-risk after endoscopy can be fed after 24hrs
If patient having undergone endoscopic haemostasis for high
risk stigmata should be hospitalised for at least 72hrs
thereafter
Bleeding peptic ulcer and duodenal ulcer – should have
testing for H. Pylori but not when acute bleeding. C14 urea
breath test, serology- should receive eradication with
confirmation of eradication(2weeks later)
E-Mediation review
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In patients with prior ulcer bleed who require an NSAID, it
should be recognized that treatment with traditional NSAID
plus PPI or a COX-2 alone still associated with clinically
important risk of bleeding
In patients with prior ulcer bleeding who require NSAID the
combination of PPI and cox-2 is recommended to reduce the
risk of recurrent bleeding from that of cox-2 alone.
Inpatients receiving low-dose ASA who develop an acute ulcer
bleed, ASA should be started as soon as the risk of
Cardiovascular complication is thought to outweigh the risk of
bleeding.
In patients with a prior bleed who require CVA prophylaxis it
should be recognized that clopidrogel alone has a higher risk
of rebleeding vs ASA and PPI
A good discharge summary with follow-up plan. Discuss with
GP before discharge. If plan for re-scoping don’t forget RFA
Resident of the team
Clinical Pearls
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History, clinical exam, sedation issues and resuscitation
Please take note of the operative report (Endoscribe/ ProvationMD
database)
Post-operative plan
High risk patients – Potential rebleeding
Medication – to be restarted/ withheld
Discharge planning and follow-up
Discharge summary – Upper GIH
- Cause identified * where is the lesion?
- Treatment, risk of rebleed,variceal banding
- medication update
- Further follow-up….
- Talk to the GP – Ensure updated
medication list and H.pylori testing
Outstanding pathology results
In the last 12months
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Inappropriate resuscitation – PPI infusion, IV fluids, NBM
Nursing Monitoring – Prolonged hypotension – No review
Bright PR bleeding noted by family, nursing staff, medical
RMO and Registrar aware but gastroenterologist not informed
ED noted Haematemesis and malaena but discharge home
without endoscopy
Peripheral shutdown, difficult access, call made to ICU for
cannula assistance. Metcall Vs consult
Delay in referral made to gastroenterologist for patient with
HB 56!
No discussion with operation suite for add on emergency list
NO per-rectal examination- carried information from triage,
patient, ED staff. PLEASE DO IT YOURSELF.
Summary
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A good history and proper clinical examination
Per-rectal examination
Resuscitate the patient, risk assessment
Plan for endoscopy discussed with gastroenterologist
Medical registrar/AT to be aware of the patient
Most GIH will stop spontaneously
however, only endoscopy will identify which lesions will not
therefore:
never assume that a lesion is
controlled without endoscopy
Thank you
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Course notes from the 4th Annual Westmead Endoscopy
Symposium,3rd and 4th March 2011.
Dr.Gurvinder rull- Article on Upper GIH
Practical gastroenterology and Hepatology- Nicholas
J.talley,Kemeth R.devault,David E.Fleischer
Prof. Aidan Foy slides.