FRCA Notes

Upper GI Bleeding

Resources

  • Upper GI bleeding refers to bleeding from the GI tract proximal to the DJ flexure
  • Overall incidence is decreasing but still in the region of 75-175/100,000
  • On ICU the incidence of GI bleeding from stress ulcers is up to 8.5% (but 15% without SUP)

  • Mortality is to the tune of 5,000 deaths/yr
    • Up to 7% mortality among new presentations
    • Up to 30% mortality in those who bleed as inpatients


Ulcerative Portal Hypertension Neoplastic
Peptic ulcer (>50%) Gastric or oesophageal varices Lieomyoma
Gastritis, oesophagitis Hypertensive gastropathy Polyp
Stress ulcers Vascular malformation
e.g. Dieulafoy's lesion 		Adenocarcinoma
Drug-induced e.g. NSAIDs
Alendronate		 Hereditary hemorragic telangiectasia Carcinoid syndrome
Zollinger-Ellison syndrome Mallory-Weiss tear Lymphoma
Infective e.g.
H. pylori, Candida, CMV		 Post-surgical


  • Haematemesis
  • Malaena
    • Tend to present later, with lower [Hb] and higher transfusion requirements
    • Lower mortality than those presenting with haematemesis
  • Features of hypovolaemia e.g. syncope, postural dizzinesss
  • Features of haemorrhagic shock

Brief history

  • Age >60yrs associated with increased mortality

  • PMHx
    • Chronic liver disease ± known varices
    • Previous UGIB (60% of those who bleed have bled before)
    • Major commorbidities (poorer outcome)
    • Recent GI surgery

  • DHx e.g. NSAIDs, anticoagulants

Risk stratification

  • Risk stratification systems include Glasgow-Blatchford and Rockall; the former may be better

Airway & breathing

  • Failure to protect the airway is an important cause of delayed mortality
  • Aspiration is common due to:
    • Active vomiting/haematemesis
    • Loss of airway reflexes from reduced consciousness (encephalopathy, haemorrhagic shock)

  • Intubate the patient, anticipating a difficult airway
  • Supplemental oxygen as required

Cardiovascular

  • For the most part this follows a standard major haemorrhage patter
  • I.e. targeted management of haemorrhagic shock with ongoing assessment of end-organ function
  • Ideally one should resuscitate the patient prior to endoscopic/surgical intervention, but it may need to occur simultaneously

  • Multiple wide-bore intravenous access ± arterial line
  • Bloods to include an FBC, U&E, LFTs, clotting, blood gas and TEG/ROTEM
  • Resuscitation with warmed, IV balanced crystalloids in the first instance
  • Target an SBP of 90mmHg initially

  • Activation of a major haemorrhage protocol
    • There were no differences in outcome between restrictive and liberal transfusion strategies (TRIGGER study, 2015)
    • Target platelets >50x109/L
    • Give FFP if INR >1.5
    • Manage hypofibrinogenaemia with cryoprecipitate or fibrinogen concentrate if <1.5g/L after FFP
    • Reverse existing coagulopathy e.g. PCC, vitamin K, FFP

  • Terlipressin 2mg IV QDS is indicated if it's a variceal bleed
    • Give for up to 5 days
    • To cause splanchnic system vasoconstriction and reduce portal blood flow
  • If for whatever reason you can't get hold of terlipressin, octreotide is another option

    • A Sengstaken-Blakemore tube can be inserted for precipitous bleeding as a bridge to endoscopy
      • Double-cuffed gastric tube that controls bleeding in 90% of cases
      • Inserted into stomach and gastric cuff inflated with 150 - 200ml air
      • If ongoing bleeding, can inflate oesophageal cuff to 30 - 40mmHg
      • Complications of use include oesophageal ulceration/rupture, gastric necrosis, aspiration and airway obstruction
      • Can be left in situ for up to 24hrs

  • NB TXA is not indicated as per the HALT-IT trial

Other care

  • Broad-spectrum antibiotics in variceal bleeding for 7 days
    • Reduce in-hospital mortality 20%
    • Gram negative bacteria are common
  • H.pylori eradication in those who test positive

  • Erythromycin 250mg pre-endoscopy may improve endoscopic outcomes and reduce length of stay but is not recommended by NICE

  • PPI infusion for 72hrs following endoscopy
    • May reduce re-bleeding by raising gastric pH, preventing clot lysis by inhibiting mucosal fibrinolysis
  • Early re-introduction of anti-thrombotic/-platelet therapies once haemostasis achieved to reduce long-term morbidity from thrombotic events

Endoscopic

  • Endoscopy should be performed within 24hrs, and sooner if active bleeding

  • Adrenaline injection
  • Thermocoagulation
  • Variceal ligation e.g. with clipping or banding
  • Sclerotherapy

Other

  • Surgical oversewing of the ulcer
  • Partial gastrectomy
  • TIPSS
    • Hepatic vein cannulation via the IJV
    • Tract to portal vein created through liver parenchyma and a stent deployed in it
    • Connects portal and systemic circulations
    • Reduces portal pressures at the expense of a 25% risk of encephalopathy and 1% procedural mortality