Upper Gastrointestinal Bleeding

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Upper Gastrointestinal Bleeding

• Dr Bernard Stacey
• Consultant Gastroenterologist

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Upper GI bleeding

• Variceal
• Known varices
• Signs of chronic liver disease
• Prolonged INR
• Low platelets
• (Alcohol history)

• Non-variceal
• NSAID use
• Preceding dyspeptic symptoms
• M-W tear history

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Lower GI bleeding

• Previous history of similar events
• Bright red PR bleed
• Dark red PR bleed
• Unless massive upper GI bleed
• Normal urea

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Trials investiging a raised urea as a predictor
of UGIB v LGIB (or no bleed)

• USA 6, Europe 6, Japan 4, SA 1
• Twice as many retrospective trials
• 1729 patients
• Sensitivities 54 95
• Specificities 27 100
• 10 trials in favour, 2 against

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• Best results if blood sample taken 6-12 hours
  after event

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OGD findings   Varices DU/GU/pyloric
ulcer Gastritis (NSAIDs) Oesophageal
ulcer Normal Cancers Oesophagitis
Dielafoy Miscellaneous
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Acute Resuscitation

• A B C
• not
• OGD

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Acute Resuscitation

• Airway protection
• Breathing (oxygenation)
• Circulation (BP, postural drop)
• N/Saline, blood
• (FFP)
• (Platelets)

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Acute Resuscitation (2)

• Endoscopy
• Allows direct visualisation
• Heater probe, endoclips
• Injection with adrenaline, ethanolamine
• Band ligation
• Rebleed rate 15 20

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On Call Endoscopist

• Aim for OGD within 24 hours of admission
• Endoscopy at night if
• Severe haemodynamic upset (pulse, BP)
• Varices
• Otherwise endoscope next morning
• Discussion of management

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Variceal bleeding

• Venous bleeding
• Usually an associated coagulopathy
• Drug administration recommended as early as
  possible (before endoscopic therapy)
• Combination therapy better than drugs or
  endoscopy alone

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Risk of Bleeding

• Portal pressure - circadian change
• Highest pressures at night
• ? risk with
• severity of liver disease
• variceal size
• red markings on varix
• pressure over 12 mmHg

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Pharmacological treatment

• Similar effectiveness to sclerotherapy
• Terlipressin (Glypressin) - Synthetic vasopressin
• bolus administration but may need nitrates if
  angina provoked
• Beneficial effects temporary so endoscopy still
  necessary
• Antibiotics (cefotaxime)

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? blockers

• Propranolol, nadolol
• Lower risk of rebleeding by 40
• Lower mortality by 20
• Splanchnic haemodynamics unpredictable
• Not an acute drug

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Non-variceal bleeding
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Non-variceal bleeding

• Endoscopy is the key to effective treatment
• Proton pump inhibitors / H2 receptor antagonists
  not effective in stopping active bleeding
• But clot stabilisation

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The Vessel

• Artery protruding above ulcer floor 33
• Clot protruding above ulcer floor 65
• ? not simply an acute excess acid problem
• Aneurysm formation in 51
• true 42 false 58

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Proton Pump Inhibitors

• Actively bleeding ulcers / visible vessel
• ? adrenaline injection thermocoagulation
• ? IV omeprazole or Placebo
• 120 120
• 8 (6.7) Rebleeding 27 (22.5)
• 5 In first 3 days 24
• 3 Surgery 9
• 5 Died 12

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Tranexamic acid

• Used as pro-coagulant in other settings
• cardiac surgery
• ENT
• menorrhagia
• Complications
• Anecdotal use for portal hypertensive gastropathy
  and gastric antral vascular ectasia (GAVE)

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Coffee ground vomit itself generally has a good
prognosis
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Think of underlying conditions MI Pneumonia GI
obstruction

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Recurrence rates

• Duodenal ulcer
• Without eradication 80 in 1 year
• With eradication 5 in 1 year

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Arterial (ulcer) v Venous (variceal) bleeding

• Arterial
• Physical measures
• Excess acid not the main acute problem
• IV drugs after OGD (but before also helps)

• Venous
• Lower pressures involved
• Associated coagulopathy
• Combination therapy best outcome
• IV drugs before and after OGD

Acute ABC resuscitation
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Any Questions?
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Summary

• Basic ABC resuscitation is imperative
• Remember coagulopathy and synthetic vasopressin
  in variceal bleeds
• Inform endoscopist
• At night if unstable
• Early the next morning if stable
• Early surgical involvement
• Acid suppression and eradication regimes