Acute Upper GI Bleed Flashcards
Acute Upper GI Bleeding - Assessment
Acute upper gastrointestinal bleeding
NICE published guidelines in 2012 on the management of acute upper gastrointestinal bleeding which is most commonly due to either peptic ulcer disease or oesophageal varices. Some of the key points are detailed below.
Risk assessment
use the Blatchford score at first assessment, and
the full Rockall score after endoscopy
Blatchford Score
Blatchford score
Admission risk marker > Score
Urea (mmol/l): 6·5 - 8 = 2 8 - 10 = 3 10 - 25 = 4 > 25 = 6
Haemoglobin (g/l): Men 12 - 13 = 1 10 - 12 = 3 < 10 = 6
Women
10 - 12 = 1
< 10 = 6
Systolic blood pressure (mmHg):
100 - 109 = 1
90 - 99 = 2
< 90 = 3
Other markers
Pulse >=100/min = 1
Presentation with melaena = 1
Presentation with syncope = 2
Hepatic disease = 2
Cardiac failure = 2
NB: Patients with a Blatchford score of 0 may be considered for early discharge
Low risk = Score of 0. Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery.
Acute Upper GI Bleed - Resuscitation
Resuscitation
ABC, wide-bore intravenous access x 2
platelet transfusion if actively bleeding AND platelet count of less than 50 x 10*9/litre
fresh frozen plasma to patients who have either a fibrinogen level of less than 1 g/litre, or a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal
prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
Acute Upper GI Bleed - Endoscopy
Endoscopy
should be offered immediately after resuscitation in patients with a severe bleed
all patients should have endoscopy within 24 hours
Acute Upper GI Bleed - Non-Variceal Bleeding Mx
Management of non-variceal bleeding
NICE do not recommend the use of proton pump inhibitors (PPIs) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding although PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy
if further bleeding then options include repeat endoscopy, interventional radiology and surgery
Acute Upper GI Bleed - Variceal Bleeding Mx
Management of variceal bleeding
terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
Antiplatelets in Upper GI Bleed - Example Question
A 68-year-old man who is on aspirin following a myocardial infarction 2 years ago has been admitted and treated successfully endoscopically for a non-variceal upper gastrointestinal bleed with clips and adrenaline. What should be done in the acute phase with regards to this patient’s aspirin therapy?
Stop aspirin Replace aspirin with clopidogrel > Continue aspirin Replace aspirin with low molecular weight heparin Replace aspirin with unfractionated heparin
NICE guidelines indicate that in patients following an upper gastrointestinal bleed in whom haemostasis has been achieved, aspirin should be continued when it is being used for secondary prevention of vascular events.
There is no need to replace aspirin with clopidogrel or either form of aspirin or heparin in this setting.
For more information, please use the following link:
https://www.nice.org.uk/guidance/CG141/chapter/1-Guidance#control-of-bleeding-and-prevention-of-re-bleeding-in-patients-on-nsaids-aspirin-or-clopidogrel
Acute Upper GI Bleed - Rebleeding
Re-bleeding can occur in approximately 15% of patients who had previously been treated and this rate of re-bleeding increases in parallel with the severity of the original bleed. Operative intervention is much more effective than conservative management in the case of re-bleeding and although omeprazole and somatostatin can be used in conjunction with operative treatment, the risks associated with re-bleeding mean operative intervention is an absolute indication. There are similar mortality rates for endoscopic treatment and open surgery in patients who have had re-bleeding following an earlier successful endoscopic treatment.
Example Question:
A 58 year-old woman presents to hospital after 2 episodes of vomiting up blood. It began 2 hours prior to presenting at hospital and the patient was at work as a saleswoman at the time. She has a past history of a duodenal ulcer and also suffers from irritable bowel syndrome, hypertension and hypercholesterolaemia. Her regular medication includes simvastatin and ramipril. She is admitted under the gastroenterology team and undergoes fluid resuscitation and successful sclerotherapy. The next morning, the patient vomits up a moderate amount of blood.
What is the most appropriate management?
Intravenous omeprazole Conservative management Intravenous somatostatin > Repeat sclerotherapy endoscopically Refer to a general surgeon for open surgery
Endoscopic treatment is preferable in this case.
Oesophageal Varices - Acute Mx of Varcieal Haemorrhage
Acute treatment of variceal haemorrhage
ABC: patients should ideally be resuscitated prior to endoscopy
correct clotting: FFP, vitamin K
vasoactive agents: terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding. Octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality
prophylactic antibiotics have been shown in multiple meta-analyses to reduce mortality in patients with liver cirrhosis. Quinolones are typically used.
endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
Oesophageal Varices - Preventative Mx
Prophylaxis of vatical haemorrhage
Prophylaxis of variceal haemorrhage
propranolol: reduced rebleeding and mortality compared to placebo
endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration
Oesophageal Varices - Mx: Example Question
A 60-year-old lady on the gastroenterology ward develops an acute episode of haematemesis in the night, the nurse who witnessed the event described the bleed as about one cupful of bright red blood. The patient has a known history of alcohol abuse, drinking 2 bottles of wine a day, and has a past medical history of ascites secondary to alcoholic liver cirrhosis, hypertension and type two diabetes mellitus. She was admitted initially for an ascitic drain earlier in the afternoon which has not occurred due to staff shortages in the medical team.
On examination she was afebrile, her heart rate was 110bpm, blood pressure was 104/81mmHg, respiratory rate of 20 breaths per minute and had an oxygen saturation of 97% on air. Cardiovascular and respiratory examination was unremarkable. Abdominal examination revealed a tensely distended abdomen with shifting dullness present. There are marked distended superficial veins on her abdominal surface. There was mild epigastric tenderness, and on rectal examination, there was a small amount of tarry black stool. She was not actively vomiting during the examination.
Intravenous fluid resuscitation was already started by the house officer on call, and blood samples including a cross-match were sent. The gastroenterology registrar on call has been informed and was arranging an emergency endoscopy for the patient.
Her previous blood results and a current venous blood gas (VBG) results are shown:
Blood results (earlier in the afternoon)
Na+ 134 mmol/l K+ 4.8 mmol/l Urea 10.9 mmol/l Creatinine 100 µmol/l Serum bilirubin 30 µmol/l Serum alkaline phosphatase 165 IU/l Serum aspartate aminotransferase 68 IU/l C Reactive protein 6 mg/l Haemoglobin 126 g/l White cell count 7.6 x 10^9/L Platelets 122 x 10^9/L INR 1.8
VBG (Current)
pH 7.368 Lac 1.8 mmol/l Base Excess -2.4 mmol/l Bicarbonate 26.9 mmol/l Hb 11.0 g/dL
What is the next most appropriate immediate course of action to take?
Begin transfusion of O-negative blood Intravenous proton pump inhibitor (PPI) bolus > Intravenous terlipressin bolus Platelet transfusion Intravenous ciprofloxacin
This clinical picture is strongly suspicious for a variceal upper gastro-intestinal (GI) bleed, and the principles of management should be initial resuscitation with intravenous fluids with two large bore cannulas. A blood transfusion should be arranged, however, although the patient is tachycardic she is still maintaining her blood pressure and the VBG result suggests she could wait for a cross-matched sample to be ready instead of requiring immediate O-negative blood which is limited in supply. An endoscopy should be offered immediately after resuscitation to all unstable patients for band ligation of the bleed.
NICE guidelines for variceal bleeds recommend both intravenous terlipressin and antibiotic prophylaxis prior to endoscopy. Of the two, there is a significant improvement in the rate of patients achieving initial haemostasis in patients treated with terlipressin due to its vasopressive effect in decreasing portal hypertension and would be the more appropriate drug to give first. Terlipressin should be stopped after definitive haemostasis has been achieved, or after 5 days of therapy. As this patient has a platelet count of greater than 50 x 109/L a platelet transfusion is not indicated, however, she is coagulopathic and would benefit from both vitamin K and fresh frozen plasma.
Intravenous proton pump inhibitors have a limited evidence base in the pre-endoscopy management of upper GI bleeds in decreasing the mortality from variceal bleeds, and are not included in the current NICE guidelines for the management of variceal bleeds.
Acute Variceal Bleed: Pharmacological Mx - Example Question
Example Question:
A young man known to the gastroenterology team with alcoholic cirrhosis and grade two varices on his last OGD 7 months ago is admitted as a medical emergency to the resuscitation part of Accident and Emergency with haematemesis and melaena. It started 45 minutes ago when he immediately called an ambulance. He is able to tell you that apart from the cirrhosis and varices he does not have any other problems, and he takes only thiamine, vitamin B co-strong and propranolol (but he is unsure of the dose). He says he has been well over the past week, with no symptoms of disease, and your screening questions reveal nothing important. He admits that he still occasionally drinks alcohol, but hasn’t in the past 2 weeks, and that he used to have an opiate based drug addiction, for which he’s been clean the past 3 years.
His initial observations are as follows:
Respiratory rate 22 breaths/minute Heart rate 102 beats/minute Temperature 36.2ºC Blood pressure 85/33 mmHg Saturations 100% on 4L nasal
Initial bloods
Hb 90 g/l
Platelets 72 * 109/l
WBC 6.4 * 109/l
His ECG shows RBBB and T wave inversion in leads V1 and V2 only.
After 3L of fluid resuscitation:
Hb 78 g/l
Platelets 63 * 109/l
WBC 5.9 * 109/l
Na+ 129 mmol/l
K+ 4.2 mmol/l
Urea 14.2 mmol/l
Creatinine 75 µmol/l
Bilirubin 43 µmol/l
ALP 152 u/l
ALT 41 u/l
Albumin 29 g/l
PT 20.4 s
INR 1.7
APTT 38 s
Fibrinogen 0.8 g/L
His repeat observations are as follows:
Respiratory rate 18 breaths/minute Heart rate 92 beats/minute Temperature 36.4ºC Blood pressure 105/65 mmHg Saturations 99% on 2L nasal
What medication would you give him?
> Fresh frozen plasma, Terlipressin, Ceftriaxone Fresh frozen plasma, Terlipressin, Ceftriaxone, Platelets, Packed red cells Fresh frozen plasma, Ceftriaxone, Platelets Fresh frozen plasma, Terlipressin, Ceftriaxone, Packed red cells Fresh frozen plasma, Terlipressin, Packed red cells, Platelets
Guidelines issued by the British Society of Gastroenterology and NICE:
Packed Red Cells: Transfuse as per local massive bleeding protocol, recognising that over transfusion is as damaging as under transfusion and that a restrictive transfusion policy (aiming for 70-80 g/L is suggested in haemodynamically stable patients. As this patient is no longer vomiting blood and appears to be haemodynamically stable (as shown by the reducing pulse and rising blood pressure, transfusion is not required.
Platelets: Do not offer platelets to patients who are actively bleeding and are haemodynamically stable. To those still actively bleeding, offer platelets if count is <50 x 109/L. This patient does not need platelets as his platelet count is above the threshold at which it would be beneficial.
Fresh Frozen Plasma: Offer to those with a fibrinogen <1 g/L or a PT/APTT/INR over 1.5 times the normal value.
Antibiotics: All patients with acute variceal bleed should be offered antibiotics with Gram-negative cover.
Proton Pump Inhibitors: This is an issue that requires further research and thus has not been included in the question. The main concern is that in the small number of trials done on the role of PPIs in acute variceal bleed there has been no improvement in bleeding or survival. In addition to this it increases the risk of spontaneous bacterial peritonitis.
Terlipressin: Reduces failure to control bleeding and improves survival. The recommended dose is 2mg IV every 4 hours, but most centres reduce the dose to 6 hourly due to its vasoconstrictive effects causing painful hands and feet. Prolonged treatment with terlipressin has not been shown to improve survival further and thus treatment should be stopped shortly after satisfactory haemostasis has been achieved.
Acute Duodenal Ulcer Bleed - Example Question
A 60-year-old man is admitted with severe upper abdominal pain, nausea and dizziness lasting for the last day. On further questioning he admits to experiencing intermittent mild upper abdominal pain for the last month, typically after meals. His past medical history includes hypertension, type 2 diabetes, osteoarthritis and myocardial infarction 5 years ago for which he had a stent placed. His current medications include aspirin, ramipril, amlodipine, metformin, naproxen and paracetamol.
Whilst in the department he develops diarrhoea and examination of the stool shows melaena.
His blood pressure is 110/55 mmHg and heart rate is 95 beats per minute. On examination, he is tender in the epigastrium with no peritonism and normal bowel sounds. Examination of other systems is normal.
Blood results:
Hb 95 g/l Na+ 145 mmol/l Platelets 200 * 109/l K+ 4.5 mmol/l WBC 8 * 109/l Urea 12 mmol/l Neuts 3 * 109/l Creatinine 102 µmol/l
He is treated given intravenous fluids and analgesia. All his regular analgesia aside from paracetamol is withheld. and taken to endoscopy later that day. A 1cm ulcer is seen in the gastric antrum with an adherent clot. This is clipped and injected with adrenalin. He recovers well from sedation and on return to the ward his blood pressure is 135/70 mmHg and heart rate 80 beats per minute. He has no further diarrhoea or vomiting and repeat haemoglobin is 121 g/l.
On discharge, what advice should he be given regarding his non-steroidal anti-inflammatory drugs?
Continue both aspirin and naproxen and add a proton pump inhibitor Stop naproxen and aspirin. Start a proton pump inhibitor. Stop naproxen, change aspirin to clopidogrel and add a proton pump inhibitor Stop naproxen, change aspirin to dalteparin and add a proton pump inhibitor > Stop naproxen, continue aspirin and add a proton pump inhibitor
This gentleman has an upper GI bleed due to a gastric ulcer. This may be related to his use of non-steroidal anti-inflammatory drugs (NSAIDS) aspirin and naproxen, NICE guidelines recommend continuing aspirin for secondary prevention of vascular events (as in the gentleman with previous myocardial infarction) providing haemostasis has been achieved. All other NSAIDS should be discontinued and so naproxen should be stopped.
Proton pump inhibitors are recommended for all those with non-variceal bleeding and stigmata of recent haemorrhage at endoscopy.
National Institute for Health and Clinical Excellence. Acute upper gastrointestinal bleeding. (2012) NICE guideline CG141.
Indication for Sengstaken Blakemore Tube:
A 48-year-old known alcoholic liver disease patient is admitted via Accident and Emergency with profuse haematemesis. He has been drinking 6 litres of cider per day for the last week. He denies abdominal pain or melena. On examination, he has peripheral stigmata of chronic liver disease and is very pale. His abdomen is soft and he has no tenderness or hepatosplenomegaly. His blood pressure is 90/56 mmHg and he is tachycardic at 120/min. His last OGD 6 months ago showed 3 columns of small varices.
His blood results are as follows:
Hb 58 g/l Platelets 109 * 109/l WBC 8.4 * 109/l INR 1.6 PT 19 seconds
Na+ 144 mmol/l K+ 4.9 mmol/l Urea 18.1 mmol/l Creatinine 97 µmol/l CRP 5 mg/l
Bilirubin 87 µmol/l
ALP 189 u/l
ALT 71 u/l
Albumin 28 g/l
He is transfused 2 units by A&E and given 2 units of Fresh Frozen plasma to correct his coagulopathy. He is also given Tazocin 4.5g TDS and Terlipressin 1mg QDS after discussion with the on call Gastroenterologist. He is taken for OGD which shows bleeding oesophageal varices. He has 5 bands applied to the varices but the endoscopist is unable to stop the bleeding. He is returned to the ward were he continues to have haematemesis with low blood pressure and ongoing tachycardia.
What is the next step in his management?
Repeat OGD TIPSS > Sengstaken Blakemore tube Increase Terlipressin to 2mg Further FFP
This gentleman has had a large variceal bleed. This is reflected in his low Hb and high urea. His initial management is appropriate and if haemostasis cannot be achieved then the next step is determined by the patient. If he is stable then a repeat OGD can be performed to try and stop the bleeding but if he is unstable then tamponade of the varices with a Sengstaken Blakemore tube is needed whilst the patient is resuscitated. TIPSS may be a potential treatment option in this patient but would usually follow Sengstaken tube insertion
Variceal Bleed and Abx: Example Question
A 37-year-old man is reviewed on the gastroenterology ward. He has a history of alcoholic liver disease was admitted following a large haematemesis. After admission he had an emergency endoscopy where oesophageal varices were identified and banded. Intravenous terlipressin has already been given. What is the most appropriate next step in management?
Oral metronidazole Oral nifedipine Oral tranexamic acid Oral co-amoxiclav > Oral norfloxacin
Antibiotics have been shown to reduce the risk of rebleeding in patients with acute variceal haemorrhages. Quinolones are the treatment of choice, although some studies have shown benefit from intravenous cephalosporins.
