Acute upper gastrointestinal haemorrhage

Presentation

  • Malaena
  • Haematemsis
  • Haematochezia

History

Past medical history - Cirrhosis, liver disease, HBV, HCV,
Alcohol history
Travel history - Assess risk of H.Pylori infection if the patient has been travelling to an area where it is endemic

Examination

Perform a digital rectal examination to assess for melena which is associated with upper GI bleeds
Signs of chronic liver disease - Jaundice, encephalopathic flap, spider naevi, palmar erythema, ascities
Assess for shock (systolic BP<100, pulse >100 bpm)

++Bedside tests
Perform risk assessments
Blatchford score at first assessment
Rockall score after endoscopy (scores of <3 can be considered for early discharge)

Initial management

  • Gain large calibre IV access – give crytalloids until blood arrives if patient is tachycardic or hypotensive
  • Request blood tests- FBC, U&E, LFTs, cross-match and clotting
  • Insert a urinary catheter to ensure adequate volume replacement and begin a fluid balance chart
  • Monitor pulse, BP and urine output
  • Consider ventilation – if GCS is <8 ventilation may be required
  • Assess for sepsis with a full septic screen - Culture ascites, blood, urine, sputum or do a CXR
  • Antibiotics – use broad spectrum antibiotics to reduce mortality by reducing the rate of early rebleeding (e.g IV tazocin or oral ciprofloxacin)
  • Terlipressin prior to endoscopy (contra-indicated in patients with ischaemic heart disease) or peripheral vascular disease
  • Blood transfusion
    • Do not offer platelet transfusion to patients who are not actively bleeding
    • Offer platelet transfusion to patients who are actively bleeding and have a platelet count of < 50 x 109/litre
    • Consider FFP if INR > 1.5 than normal and there is active bleeding
    • Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
    • Do not offer recombinant factor VIIa except when all other methods have failed

Resuscitation aims:

  • Maintain Hb at >8 g/dL
  • Systolic blood pressure >90 to 100 mmHg
  • Heart rate <100/min

Radiological investigations

Confirm diagnosis with endoscopy

  • For SEVERE gastrointestinal bleeding: Offer endoscopy to unstable patients immediately after resuscitation.
  • For all others: Offer endoscopy within 24 hours of admission

Variceal bleeding

  • Terlipressin given for 48 hours after endoscopy (discontinue after haemostasis has been achieved or after 5 days)
  • Prophylactic antibiotics
Oesophageal varices
  • First line treatment is Variceal Band ligation combined with a beta blocker
  • Consider TIPS if bleeding is not resolved
Gastric varices
  • First line treatment is endoscopic injection of N-butyl-2-cyanoacrylate
  • If this fails, consider TIPS

Non-variceal bleeding

  • Do not use adrenaline as monotherapy!
  • Endoscopic treatment can be mechanical (e.g clips), thermal coagulation with adrenaline, fibrin or thrombin with adrenaline
  • Offer PPIs if bleeding is shown at endoscopy, not before
  • Consider a repeat endoscopy for patients at high risk of rebleeding and offer a repeat endoscopy for patients who did re-bleed

Complications

Spontaneous bacterial peritonitis
Encephalopathy

  • Patients with portal HTN who develop GI bleeding from oesophageal varices (or other aetiologies), often develop encephalopathy

Bleeding

Prognosis

For vatical bleeds, it depends on the aetiology of the portal HTN leading to the development of varicose as well as liver function
1-year overall mortality of 30% to 40% for patients with bleeding from oesophageal varices

Unless otherwise stated, the content of this page is licensed under Creative Commons Attribution-ShareAlike 3.0 License