Makindo Medical Notes

Incidence

• Incidence of acute UGIB in the UK 80-170 per 100,000 per year
• Approximately 50,000-70,000 hospital admissions per year in UK

Clinical Terms for Bleeding

• Upper GI Bleed: bleeding from above the ligament of Treitz. Vomiting fresh blood or altered blood melaena
• Coffee Grounds: Vomitus with what looks like coffee grounds due to affect off gastric contents on blood. Has come to mean any dark vomitus and diagnostically not convincing. May suggest Upper GI blood loss.
• Haematemesis: Vomiting fresh blood : (upper GI bleed)
• Melaena: Passing black altered blood PR (upper GI bleed)
• Haematochezia: Passing fresh blood PR : may be due to a rapid upper GI bleed but more commonly lower GI bleed

Could this blood be swallowed from facial or dental trauma or nose bleed in someone on anticoagulants or clotting disorder or even cough and haemoptysis

Major Bleed suggested by

• Tachypnea, Tachycardia
• Orthostatic drop by 10 mmHg ++ can suggest 20% drop in blood volume
• SBP < 100 mmHg can suggest 30% drop in blood volume + pallor, cool skin
• Clammy, cold, peripherally shut down, drowsy, comatose
• Visible bleeding - Haematemesis or PR bleed

Significant Risk of death

• Continuing melaena/haematemesis/ age > 60
• Hypotensive despite resuscitation
• Chronic liver disease/coagulopathy/Variceal bleed
• Known IHD/renal failure/Disseminated malignancy

Clinical

• Are they Moribund, unconscious, Check AVPU scale
• May be coffee grounds vomit, haematemesis, melaena, hypotension, syncope,
• Ask about Aspirin, NSAIDs, Anticoagulants, anti-thrombotics, steroids, alcohol
• Look for chronic liver disease with portal hypertension, cachexia and malignancy
• Clinical anaemic, hypotensive. Postural BP drop sitting up + tachycardia
• Generally Poor capillary return. Blood may be found on PR examination.
• Try and see Melaena stool yourself if available: Iron tablets can cause dry black stools, Melaena is black and liquid and sticky

Life threatening causes: Practically for acute care it is considered as Variceal vs non variceal bleeding

• Non-Variceal (90%)
  • Gastric/Duodenal ulcer 50%
  • Oesophagitis 10%
  • Gastritis/Duodenitis 15%
  • Erosions (NSAIDs, Steroids, HP)
  • Vascular malformation 5%
  • Mallory Weiss tear 5%
  • Oesophageal or Gastric Malignancy.
  • Dieulafoy's lesion (a vascular malformation of the proximal stomach).
  • Angiodysplasia.
  • Haemobilia (bleeding from the gallbladder or biliary tree).
  • Aortoenteric fistula.
  • Bleeding diathesis.
  • Ehlers-Danlos syndrome.
  • Pseudoxanthoma elasticum.
  • Gastric antral vascular ectasia.
  • Osler-Weber-Rendu syndrome.
• Variceal (5-10%)
  • Oesophageal varices (Suspect if chronic liver disease and portal hypertension or risks (HCV, Alcohol)

Investigations

• FBC : Hb ↓ a normal Hb acutely does not exclude a significant bleed. ↓ platelets may be seen
• U&E: Urea ↑ urea out of proportion to creatinine from the protein load. A low urea often seen in liver disease
• LFTs : may show low albumin, abnormal AST/ALP
• Coagulation screen: ↑ PT with decompensating liver disease
• AXR/CXR if indicated ? perforation
• ECG if MI or arrhythmia considered
• Group and save
• Urgent endoscopy if high risk

Risk Assessment

• A formal risk assessment scores should be used for all patients with acute upper gastrointestinal bleeding
• the Glasgow/Blatchford score at first assessment and pre endoscopy and if of 0 then consider early discharge
• Use the full Rockall score after endoscopy
• High risk patients: consider urgent endoscopy
• Low risk : endoscopy within 24 hrs

Glasgow Blatchford Score

• Score based on Systolic BP, Urea and Hb and presence of Syncope, melaena, cardiac failure, liver disease
• Can be done on admission and can be done pre endoscopy and does not require endoscopy.
• Those with a score 0-1 can be managed as outpatient. Those with a value of over 5 have increased 20 day mortality. Higher cores suggests need for endoscopic therapies

Rockall Score: Post endoscopy

• Total <3 = good prognosis
• Total >8 = poor prognosis

Management

• Immediate Resuscitation
  • Get Immediate IV access x 2 in antecubital fossa and protect it. Grey, |Brown or at worst Green cannula.
  • Commence 1 L 0.9% Saline and give rapidly if shocked while awaiting blood.
  • Consider a Urinary catheter. Urine output can help inform central filling.
  • Central lines other than femoral vein (medial to nerve and artery) should not be attempted. Limited use for fluid replacement.
  • Send bloods FBC, U&E, LFTs, INR, APTT
  • Crossmatch x 4 units. Transfuse target Hb 7-9 g/dL.
  • Reverse any anticoagulation/treat coagulopathy - see below.
  • Stop any antihypertensive therapy or medications that lower BP
  • If exsanguinating act quickly Get and give O negative blood. Get senior help quickly. Crossmatch and consider massive transfusion protocol. Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion.
  • Airway or vascular access issues get anaesthetic help and call endoscopist and surgeons.
  • Patients presenting with gastrointestinal bleeding and underlying ascites due to cirrhosis should receive prophylactic antibiotic treatment (cefotaxime has been widely studied but the antibiotic should be chosen based on local data) to prevent the development of SBP
• Endoscopy for Peptic ulcer disease
  • Endoscopy: If stable scope on next list. If unstable discuss with endoscopist and have calculate the GBS first and know the history and comorbidities.
  • Plan to scope all within 24 hrs and those with active bleeding urgently.
  • Peptic ulcer bleeding high-risk stigmata e.g. active bleeding, non-bleeding visible vessel, adherent clot. Erosions can bleed profusely and be very difficult to control.
  • Endoscopic haemostasis techniques. These reduce mortality, rebleeding and the need for surgery. Use injection therapy, thermal treatments, mechanical adjuncts, spray therapy. Rebleeding seen in up to 23%. All endoscopies should include a rebleed plan.
  • Use of PPI: Some give pre-endoscopy but it can mask diagnosis and so generally avoided. Take advice and Follow local policy. Clot stability helped by an alkaline environment.
  • Omeprazole 80 mg IV bolus followed by 8 mg/hr infusion for 72 h) after endotherapy for peptic ulcer was superior to placebo in reducing recurrent bleeding, transfusion requirements and hospital stay.
  • Check HP screen may be CLO test or stool antigen test. Consider Helicobacter eradication with 7-day course of PPI and Amoxicillin and Clarithromycin or Metronidazole
  • Endoscopy signs of recent bleed from an ulcer: Spurting vessel, prominent vessel, fresh adherent clot.
• Patient not stabilsing and in extremis: get senior help
  • In some cases angiography may be indicated and embolisation of a bleeding vessel may be attempted
  • It is uncommon but all Upper GI bleeding that fails to settle with endoscopic and other techniques becomes surgical and may need emergency laparotomy and direct action to stop blood loss.
• Variceal UGIB (known or high suspicion*)
  • Avoid Saline and instead use IV Dextrose or Colloid or FFP as needed.
  • Terlipressin 2 mg IV over 5 mins QDS for 48-72 hrs use significantly reduced mortality. Contraindicated if a history of IHD. May be given with nitrates.
  • Alternative to Terlipressin is Octreotide 50 mcg IV bolus and then 50 mcg/hour IV for 5 days
  • Antibiotics: Broad-spectrum antibiotics e.g. Ceftriaxone 1g od IV
  • A Sengstaken-Blakemore tube may be necessary for massive or ongoing bleeding. This may require sedation and intubation first. Take anaesthetic advice. The gastric balloon is inflated with 300 mls of air and the tube held in place with two tongue depressors taped together and padded (to avoid pressure on lips). A CXR should be performed to confirm the correct position.
  • Endoscopic options: contact gastroenterology for urgent band ligation, sclerotherapy. Oesophageal stenting is being used.
  • Discuss further interventions e.g. TIPSS with Gastroenterology Consultant
  • Follow up: Arrange surveillance scope in one week. Commence Propranolol which reduces portal pressures
• Managing Anticoagulation/Coagulopathy and bleeding (Take haematology advice in difficult cases)
  • Stop any anticoagulants find otu when last taken
  • Warfarin: INR > 1.5. Give IV Vitamin K and 4 factor Prothrombin complex concentrates (PCC) even if metal valves if life threatening bleeding.
  • DOAC: Dabigatran - Idarucizumab (Praxbind) is specifc antidote
  • DOAC: Apixaban and rivaroxaban - Andexanet alfa
  • Offer platelets infusion if count is 50 x 10⁹/litre.
  • Fresh frozen plasma: to patients who are actively bleeding and have a PT or APTT greater than 1.5 times normal.
  • Cryoprecipitate if fibrinogen level < 1.5 g/litre despite FFP

References

• NICE Guidance on Upper GI Bleeding