Upper GI Bleeding

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Upper GI Bleeding

• Dr.Vimalan Ambikaipaker
• Gastro Advanced trainee
• JHH
• blood and guts

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Upper GIH

• Potential life threatening problem
• Upper GIT is 4times more common than Lower GIT
• Most common course peptic ulcer
• 80 stop bleeding
• Increasing age and co-morbidity increases
  mortality
• Important to indentify patients with low
  probability of re-bleeding from patients with a
  high probability of rebleeding.

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Upper GI anatomy
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Lower GI anatomy
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Aetiology

• Peptic ulcer disease 35-50
• Duodenal ulcers 25
• Gastric Ulcer 20
• Gastroduodenal erosions 8-15
• esophagitis 5-15
• Esophageal varices 5-10
• Malignancy 1
• AVM 5

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Aetiology - rare

• Dieulafoys lesions
• Angiodysplasia
• Haemobilia
• Pancreatic pseudocyst and pseudo aneursym
• Bleeding diathesis
• Ehlers-danlos syndrome
• Gastric antral vascular ectasia
• Rendu-osler-weber-syndrome
• Pseudoxanthoma elasticum

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NVUGIB Consensus Guidelines

• A - Resuscitation, risk assessment and
  pre-endoscopy management
• B - Endoscopic management
• C Pharmacological management
• D Non-endoscopic, non- meds in hospital
  treatment
• E Medication review, ASA, Clopidrogel, warfarin
  dabigratan (Pradaxa) and NSAIDS.
• F Discharge planning and Communication to GP
• G Need for gastro liaison service to be involved

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A - Resuscitation, risk assessment and
pre-endoscopy management

• History taking
• gtvomiting large amounts of red blood (active
  bleeding)
• gtCoffee-ground vomitus (older-non active
  bleeding)
• gt History melaena (black, tarry, smelly,
  difficulty to flush and iron tablets)
• gtHaematochezia in rectum
• ? Bowel obstruction
• Weight lost, diffuse or localised abdominal,
  retching

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History

• Co- morbidity and risk factors
• GERD, Peptic ulcers ,alcohol intake ,bleeding
  before
• Liver cirrhosis
• Liver malignancy
• Haematological disease Low platelets, bleeding
  diathesis
• Abdominal Aneurysm
• Lung disease ,OSA, sedation issues

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Medications

• Aspirin
• Clexane
• Clopidrogel
• Dabigratan (pradaxa)
• Warfarin
• NSAIDS
• Steroids
• Iron tablets and bismuth
• Sedation issues opiods,Marijuana,Methadone

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Examination

• Vital signs
• Signs of chronic liver disease
• Decompensated liver disease
• Acute abdomen
• Encephalopathy
• PR rectal examination

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A - Resuscitation, risk assessment and
pre-endoscopy management

• ABC
• 2 IV lines
• FBC,U/E, LFT, Coags, group and save/
  crossmatch,ECG
• Need for FFP, Prothrombin X and platelets and
  correct coagulopathy(lt2.5)
• IV fluid resuscitation
• Blood transfusion (Hblt70)
• Imaging CXR and AXR
• IV PPI Infusion and consider OCTREOTIDE infusion
  if suspect varices bleed.
• Reduce risk of aspiration , IV maxolon or IV
  erythromycin)
• Aims- BP gt100mmHg,HRlt100bpm,HCTgt24,Plateletsgt50
• Correct INR,? ICU/Haematologist
• Urgent endoscopy
• Contact gastroenterologist on call (Urgency made
  clearly to the consultant)

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A - Resuscitation, risk assessment and
pre-endoscopy management

• PPI Infusion
• Before endoscopy, accelerate the resolution of
  endoscopic stigmata of bleeding ulcers and reduce
  the need for endoscopic therapy but should not
  delay endoscopy.
• Does not result in improved clinical outcomes
  such as decrease transfusions, rebleeding,
  surgery or death.
• PPI initiated after endoscopic diagnosis of
  peptic ulcer bleed significantly reduces
  rebleeding and surgery rates
• Effects are more pronounced in Asian compared to
  with non-Asian populations
• Continue IV infusion for 3days
• Octreotide infusion
• Reduces rebleeding rates similar to endoscopic
  sclerotherapy
• Continue infusion for 5days

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Risk assessment

• Rockall Score
• Factors Age,shock,C0-mobidity,Diagnosis
• Major stigmata blood in GI tract, adherent
  clot, visible and spurting vessel
• rebleeding
• Longer stay in hospital
• Rescoping
• But always use clinical judgement

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How to provoke homicidal rage in the
Gastroenterologist

• Tell them the patient is haemodynamically
  stable
• Dont tell them anything but fast the patient
  just in case
• Insert a venous cannula of 24 gauge or less
• Do not cross match
• Start a PPI infusion without any plans for an
  endoscopy
• Perform Faecal Occult Blood test
• Dont call them early
• Post endoscopy no blood or stool chart
  monitoring
• Fail to identify rebleeding in post endoscopy
  patients
• God gave you hands use the one finger though!!!

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What to the gastroenterologist need to know

• Accurate history
• Co-morbidity
• Medication and sedation issues
• Physical examination and PR findings
• Resuscitation Plan and monitoring plan
• Retrieval plan
• Discuss time for endoscopy or the need to be done
  in theatre
• Booking of endoscopy unit and theatre nurse in
  charge is aware. Red slip!! and consent
• Gastroenterologist needs to know early

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B- Endoscopic management

• Early endoscopy , within 24hrs
• More urgent (vomiting bright red blood or
  haematochezia
• Endoscopic hemostatic tx is not indicated for
  patients with low-risk stigmata (clean based
  ulcer, or a non-protuberant pigmented dot in an
  ulcer bed)
• Finding of clot in ulcer bed warrants target
  irrigation an attempt dislodgement and with an
  appropriate treatment of underlying lesion
  (adrenaline with APC) or PPI might be enough.
• Endoscopic hemostatic tx is indicated for
  patients with high-risk stigmata.
• Combination epinephrine with either (APC, Clip
  or sclerosant injection)
• If rebleed need second look
• Need for surgical team involvement

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Esophagus
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Esophagus
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Stomach
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Duodenum
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Video clip
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Endoscopic haemostatic Treatment
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Esophageal varices
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Stomach Varices
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Video clip
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Video clip
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D- non-endoscopic, non meds in hospital treatment

• Rockall score lt3 with low risk of bleeding or
  death can be considered for early discharge.
• Full Rockwall score gt3 indicates patients needs
  further close observation as an in patient.
  Careful monitoring needed post endoscopy
• Need for re-endoscopy
• If patient is at low-risk after endoscopy can be
  fed after 24hrs
• If patient having undergone endoscopic
  haemostasis for high risk stigmata should be
  hospitalised for at least 72hrs thereafter
• Bleeding peptic ulcer and duodenal ulcer should
  have testing for H. Pylori but not when acute
  bleeding. C14 urea breath test, serology- should
  receive eradication with confirmation of
  eradication(2weeks later)

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E-Mediation review

• In patients with prior ulcer bleed who require an
  NSAID, it should be recognized that treatment
  with traditional NSAID plus PPI or a COX-2 alone
  still associated with clinically important risk
  of bleeding
• In patients with prior ulcer bleeding who require
  NSAID the combination of PPI and cox-2 is
  recommended to reduce the risk of recurrent
  bleeding from that of cox-2 alone.
• Inpatients receiving low-dose ASA who develop an
  acute ulcer bleed, ASA should be started as soon
  as the risk of Cardiovascular complication is
  thought to outweigh the risk of bleeding.
• In patients with a prior bleed who require CVA
  prophylaxis it should be recognized that
  clopidrogel alone has a higher risk of rebleeding
  vs ASA and PPI
• A good discharge summary with follow-up plan.
  Discuss with GP before discharge. If plan for
  re-scoping dont forget RFA

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Resident of the teamClinical Pearls

• History, clinical exam, sedation issues and
  resuscitation
• Please take note of the operative report
  (Endoscribe/ ProvationMD database)
• Post-operative plan
• High risk patients Potential rebleeding
• Medication to be restarted/ withheld
• Discharge planning and follow-up
• Discharge summary Upper GIH
• - Cause identified
  where is the lesion?
• - Treatment, risk of
  rebleed,variceal banding
• - medication update
• - Further
  follow-up.
• - Talk to the GP
  Ensure updated
• medication list
  and H.pylori testing
• Outstanding
  pathology results

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In the last 12months

• Inappropriate resuscitation PPI infusion, IV
  fluids, NBM
• Nursing Monitoring Prolonged hypotension No
  review
• Bright PR bleeding noted by family, nursing
  staff, medical RMO and Registrar aware but
  gastroenterologist not informed
• ED noted Haematemesis and malaena but discharge
  home without endoscopy
• Peripheral shutdown, difficult access, call made
  to ICU for cannula assistance. Metcall Vs consult
• Delay in referral made to gastroenterologist for
  patient with HB 56!
• No discussion with operation suite for add on
  emergency list
• NO per-rectal examination- carried information
  from triage, patient, ED staff. PLEASE DO IT
  YOURSELF.

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Summary

• A good history and proper clinical examination
• Per-rectal examination
• Resuscitate the patient, risk assessment
• Plan for endoscopy discussed with
  gastroenterologist
• Medical registrar/AT to be aware of the patient
• Most GIH will stop spontaneously
• however, only endoscopy will identify which
  lesions will not
• therefore
• never assume that a lesion is controlled without
  endoscopy

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Thank you

• Course notes from the 4th Annual Westmead
  Endoscopy Symposium,3rd and 4th March 2011.
• Dr.Gurvinder rull- Article on Upper GIH
• Practical gastroenterology and Hepatology-
  Nicholas J.talley,Kemeth R.devault,David
  E.Fleischer
• Prof. Aidan Foy slides.