Upper gastrointestinal bleeding (UGIB) is defined as a potentially life threatening abdominal emergency due to hemorrhage that emanates proximal

to the ligament of Treitz.

Cerulli MA et al, Upper Gastrointestinal Bleeding, Medscape, Nov 2011

Epidemiology

The incidence of UGIB is approximately 100 cases per 100,000 population per year. The incidence of UGIB is 2-fold greater in males than in females, in all age groups, however, the death rate is similar in both sexes. The population with UGIB has become progressively older, with a concurrent increase in significant comorbidities that increase mortality. Mortality increases with older age (>60 y) in males and females.

Cerulli MA et al, Upper Gastrointestinal Bleeding, Medscape, Nov 2011

 Peptic

ulcer disease Esophageal and gastric varices Hemorrhagic gastritis Esophagitis Duodenitis

Mallory-Weiss

tear Angiodysplasia Upper gastrointestinal malignancy Anastomotic ulcers (after PUD surgery or bariatric surgery) Dieulafoy lesion

Med Clin N Am 92 (2008) 491509

Prior history of GI bleeding GI symptoms - weakness, dizziness, syncope associated with hematemesis (coffee ground vomitus), and melena. Character of GI bleeding GI medications Gastrotoxic medications Anticoagulants Social habits Medical comorbidities Other relevant history
Med Clin N Am 92 (2008) 491509

Hemodynamic stability / signs of shock

Sensorium- decreased conscious level Cold clammy extremities Tachycardia- Pulse >100bpm Hypotension- Systolic BP <100mmHg Orthostatic hypotension- Postural drop (> 20mmhg on standing) Hypoxia JVP <1cm Urine output <30mL/h

Med Clin N Am 92 (2008) 491509

Abdominal examination
Signs of chronic liver disease or portal hypertension

Hepatomegaly Splenomegaly Ascites - shifting dullness / fluid thrill Palmar erythema Caput medusa Spider angiomata Peripheral edema

Rectal examination Occult blood Gross blood Bright red blood per rectum Melena Burgundy stools Blood coating stools versus within stools Bloody diarrhea

Med Clin N Am 92 (2008) 491509

INVESTIGATIONS

CBC: haemoglobin is measured serially (4-6 hourly in the first day) to help assess trend. The requirement for transfusion is based on initial haemoglobin and a clinical assessment of shock. Crossmatch blood (usually between 2 and 6 units according to rate of active bleeding). Liver Function Tests - liver disease Coagulation profile: PT with APTT and (INR), fibrinogen level Renal function tests and electrolytes; BUN-to-Creatinine ratio (greater than 36 in renal insufficiency suggests UGIB).
Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Imaging

CXR: may identify aspiration pneumonia, pleural effusion, perforated oesophagus.

Erect and supine abdominal X ray to exclude perforated viscus and ileus.
CT scan and ultrasound can identify: o Liver disease. o Cholecystitis with haemorrhage. o Pancreatitis with haemorrhage and pseudocyst. o Aortoenteric fistulae. Nuclear medicine scans = active haemorrhage. Angiography - useful if endoscopy fails to identify site of bleeding.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Endoscopy

The primary diagnostic investigation in patients with acute UGIB: Endoscopy should be undertaken immediately after resuscitation for unstable patients with severe acute UGIB. Endoscopy should be undertaken within 24 hours of admission for all other patients with UGIB.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

MANAGEMENT
Risk assessment
The following formal risk assessment scores are used for all patients with acute upper gastrointestinal bleeding: the Blatchford score at first assessment the full Rockall score after endoscopy

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Admission risk marker

Blood Urea mmol/L

>/=6.5 -7.9 8-9.9 10-24.9 >/=25

>/=12 -13 Haemoglobin g/dL (men) 10-11.9 <10

Score 2 3 4 6 1 3 6

Haemoglobin g/dL (women)

Systolic blood pressure mmHg

Other markers

>/=10-12 <10 100-109 90-99 <90 Pulse >/=100 Presentation with malaena Presentation with syncope Hepatic disease Cardiac failure

1 6 1 2 3 1 1 2 2 2

A score of 0 identifies low-risk patients.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Score Variable Age, y 0 1 2 3 < 60 6079 >/= 80 No shock Tachycardia Hypotension Systolic BP > Systolic BP > Systolic BP 100 mm Hg 100 mm Hg < 100 mm Hg Pulse < 100 Pulse > 100 beats/min beats/min Cardiac Renal failure, failure, liver ischemic heart Nil major failure,dissemi disease, any nated major malignancy comorbidity MalloryWeiss All other Malignancy of tear, no lesion, diagnoses upper-GI tract and no SRH Blood in upper-GI tract, None, or dark adherent clot, spot visible or spurting vessel

Shock

Comorbidity

Diagnosis

Major SRH

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Assess ABCs: 1. Ensure airway is patent and clear.

2. 3. 4. 5.

Ensure adequate respiratory effort. Ensure adequate circulation. Administer 2 large IV canulas withdrawing blood for investigation. Transfuse patients with massive bleeding with blood (packed red cells), platelets and clotting factors in line with local protocols for managing massive bleeding.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

For the endoscopic treatment of non-variceal upper gastrointestinal bleeding, use one of the following: a mechanical method (for example, clips) with or without adrenaline. thermal coagulation with adrenaline. fibrin or thrombin with adrenaline.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Proton Pump Inhibitors Do not offer acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding. Offer proton pump inhibitors to patients with nonvariceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Repeat endoscopy, with treatment as appropriate. Offer interventional radiology to unstable patients who re-bleed after endoscopic treatment. Refer urgently for surgery if interventional radiology is not promptly available.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Offer terlipressin to patients with suspected variceal bleeding at presentation. Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding. Esophageal varices: Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices. Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.
Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Gastric varices:

Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with upper gastrointestinal bleeding from gastric varices. Offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection ofN-butyl-2cyanoacrylate.

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)

Summary