Upper GI Bleed

An upper gastrointestinal bleed (UGIB) is a common emergency which can be fatal if untreated.

Causes

• Peptic Ulcer Disease: Most common cause
• Gastritis or erosion of the stomach mucosa
• Mallory-Weiss Tear: This is a tear of the mucosa of the oesophagus at the gastro-oesophageal junction. It is usually caused by severe vomiting, and a history of alcohol abuse may be present.
• Oesophagitis: Would usually present with fresh blood with smaller volumes
• Oesophageal varices: These form as the left gastric vein which is draining the lower third of the oesophagus drains directly into the portal vein. Higher pressures in the portal vein (e.g. secondary to liver cirrhosis) get transmitted to the left gastric vein causing dilation and distension of these veins leading to oesophageal varices that can bleed.
• Oesophageal cancer: Small volumes of fresh blood, dysphagia, weight loss
• Drugs: NSAIDs, aspirin, steroids, warfarin and clarithromycin

Risk Factors

• NSAID use
• Dyspepsia/GORD
• Chronic Liver Disease
• Anticoagulation use

Clinical Features

• Haematemesis: Vomiting blood which can either be bright red and fresh, or may be described as ‘coffee-ground vomit’ which appears black.
• Malaena: Black, tarry stools that have a characteristic foul odour which is also another sign of GI bleeding.
• Abdominal pain
• Signs of shock
  • Tachycardia
  • Hypotension
  • Cold Peripheries
  • Pre-syncope
  • Syncope
  • Prolonged capillary refill time
  • Reduced urinary output

What is a Massive Blood Meal?

Patients with acute upper GI bleeds may have high levels of urea in the blood, out of proportion to creatinine. This indicates a ‘massive blood meal’ i.e. they've swallowed a bunch of blood. If a patient is vomiting blood, it is very possible that some of this blood will be swallowed and digested (plus there might already be blood in the stomach e.g. peptic ulcers). When red blood cells are broken down and digested, urea is produced as a waste product, resulting in high urea.

Scoring Systems

There are two main scoring systems used for risk assessing patients with upper GI bleeds.

1.    Rockall Risk Assessment: Risk of REBLEED AND MORTALITY

• Done prior to endoscopy and after endoscopy
• Prior to endoscopy, the patient’s age, blood pressure and co-morbidities are taken into account
• After endoscopy, the patient’s diagnosis at endoscopy and any signs of bleeding on endoscopy are taken into account
• Patients with low scores (0) are thought to be at lower risk of a re-bleed or death.

2.    Glasgow Blatchford Score: Risk of REQUIRING ADMISSION/INTERVENTION

• Takes into account pulse, haemoglobin, urea, melaena, co-morbidities and syncope.
• Patients with a low score (0) can be considered for discharge/not for admission/outpatient management

Initial Management and Investigations

Bedside

• ABCDE approach can help to structure the initial resuscitation/management.
  • Airway: Is the patient talking, are there signs of airway obstruction
  • Breathing
    • Oxygen saturations
    • Respiratory rate
    • Auscultation of the chest
  • Circulation
    • Blood pressure
    • Heart rate
    • Capillary refill
    • Temperature
    • JVP
    • IV access with a 2x large-bore cannula
    • Bloods
    • ECG
    • IV fluid resuscitation: This is with 500ml of a crystalloid e.g. normal saline over 15 minutes (or 250ml in elderly patients/cardiac failure)
  • Disability:
    • Glucose
    • GCS/AVPU
    • Pupils
    • Temperature
  • Exposure/everything else:
    • Abdominal examination
    • PR examination – a PR is particularly important to check for malaena

Transfusion

• Blood
  • In an emergency, 2222 can be phoned to put out a major haemorrhage protocol to receive fast O negative blood.
  • The target Hb as per the British Society of Gastroenterology (BSG) is 70-100g/L, and the transfusion threshold is 70g/L.
• Platelets:
  • If actively bleeding
  • Haemodynamically unstable
  • Platelets <50
• Clotting Factors

Bloods

• VBG/ABG: For a quick haemoglobin result
• FBC: Check haemoglobin though it may take time for an anaemia to show
• U&Es: Looking for raised urea
• LFTs: To look for underlying liver disease that might suggest the patient has oesophageal varices
• Clotting Screen: Checking for clotting abnormalities which should be corrected
• Group & Save: This involves checking the patient’s blood type and retaining a sample of their blood
• Cross Match: Physically checking the sample of blood with the blood that is intended to be transfused

Drugs

As per BSG guidance, aspirin should usually be continued at presentation of an UGIB. However, the following drugs are recommended to be stopped at presentation:

• P2Y12 inhibitors: Clopidogrel, Ticagrelor, Prasugrel etc.
• Warfarin
• DOACs: Rivaroxaban, Apixaban etc.

Definitive Treatment

Haemodynamically unstable patients with an upper GI bleed must be given endoscopy immediately following resuscitation. All other patients with upper GI bleeds should be offered endoscopy within 24 hours.^[ii]

Non-Variceal Bleeding

Non-variceal bleeding e.g. from a bleeding ulcer can be treated via:

• Mechanical methods: Clips +/- adrenaline
• Thermal coagulation and adrenaline
• Fibrin/Thrombin and adrenaline

Patients should be offered a PPI following endoscopy (although in practice you might find it's commonplace to initiate PPIs prior to endoscopy).^[iii] 

Variceal Bleeding

IV Terlipressin 2mg QDS is offered alongside prophylactic antibiotics prior to endoscopy. Endoscopic treatment is:
 

1.    Oesophageal varices: treated with band ligation on endoscopy which essentially involves tying off a bleed with a rubber band.
 

2.    Gastric varices: treated with a tissue adhesive which acts by ‘gluing’ the bleeding vein together. An example of this is N-butyl-2-cyanocrylate.

If these methods fail to control the bleed, patients can be treated with transjugular intrahepatic portosystemic shunts (TIPS). This is a procedure which involves producing a shunt between the portal and systemic circulation by diverting blood flow from the portal vein into the hepatic vein to reduce the pressure gradient between the portal and systemic circulation.^[iv] Patients can be given non-selective beta-blockers as a preventative measure for future bleeds.

References

^[i] Button LA, Roberts SE, Evans PA, Goldacre MJ, Akbari A, Dsilva R, Macey S and Williams JG. Hospitalized incidence and case fatality for upper gastrointestinal bleeding from 1999 to 2007: a record linkage study. [internet]. 2011. [cited 20^th July 2019]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21128984

^[ii] NICE. Acute upper gastrointestinal bleeding in over 16s: management. [internet]. 2016. [cited 20^th July 2019]. Available from: https://www.nice.org.uk/guidance/CG141/chapter/1-Guidance#

^[iii] Stanley AJ and Laine L. Management of acute upper gastrointestinal bleeding. [internet]. 2019. [cited 11^th August 2019]. Available from: https://www.bmj.com/content/364/bmj.l536

https://www.bsg.org.uk/wp-content/uploads/2019/11/flgastro-2019-101395.pdf

^[iv] Medscape. Transjugular Intrahepatic Portosystemic Shunt in Radiology. [internet]. 2017. [cited 11^th August 2019]. Available from: https://emedicine.medscape.com/article/420343-overview