Key facts:
Authors: Natalie Acors and Jayne Eaden
Top Tips: Normal blood pressure does not exclude significant bleed
Key Differential Diagnosis
- Lower GI bleed
- Haemoptysis
- Epistaxis (blood swallowed then vomited)
Key Investigations
- FBC (don't base resuscitation on FBC)
- U+E, LFT/GGT, Bone, Glucose ± Amylase
- INR, G+S/Cross-match 2-6 units (dependent on severity). In emergency, give O-negatve blood
- ECG, Erect CXR (perforation?)
Note: use Rockall (pre-endoscopy) or Glasgow-Blatchford Score
Key Treatment
- IV OMEPRAZOLE 40 mg od
- IV METOCLOPRAMIDE 10-20 mg stat
- Transfuse if appropriate
- ± IV TERLIPRESSIN 2mg IV stat (history suggestive of varices)
- ± IV VITAMIN K 10 mg slowly/FFP
- ± Platelets
Key Management Decisions
- Resuscitate
- Endoscopy
- Surgery
Background
The three main priorities are: (1) resuscitate the patient, and protect the airway; (2) identify the source of bleeding; and (3) organise definitive treatment, to stop bleeding
Introduction
- Haematemesis is vomiting of red blood and indicates upper GI bleeding, usually from an arterial source or varix. Melaena is a black, tarry stool and typically indicates upper GI bleeding; but bleeding from a source in the small bowel or right colon may also be the cause
- Only 100-200 mls of blood in the upper GI tract is required to cause melena, which may persist for several days after bleeding has ceased
- 80% resolve spontaneously, with no intervention at endoscopy (or surgery)
- Some patients with minor GI bleeds (especially if suspected Mallory Weiss tear) may not need an endoscopy and some can be managed as an outpatient
- Mortality is 10%, 30% in the elderly, 30% if rebleed. This has not changed in 50 years; despite advances in endoscopic techniques, ITU care etc
- Coffee ground vomit is not always due to GI bleed
Note: PPI and early endoscopy do not reduce mortality. Good resuscitation might. So, senior review ASAP if unwell, or Rockall Score ≥ 3
Definition
- Bleeding from upper GI tract, resulting in haematemesis (hematemesis) and/or melaena. Consider as a differential in patient with sudden onset collapse/shock
Epidemiology
- 50-150 per 100,000 per year (incidence)
Causes
Big 4 causes are:
- Oesophagitis/gastritis/duodenitis (40%)
- Chronic/acute peptic ulcer (duodenal > gastric); 25%, 1/3 taking NSAIDs
- Mallory-Weiss tear (alcohol history, vomiting+)
- Oesophageal/gastric varices, eg in portal hypertension
Note: Malignancy is rare (5%) but significant
[Ref]
Risk factors
- NSAIDs
- Alcohol/smoking
- Chronic liver disease
Symptoms
- Haematemesis/melaena (Gk melas = black)/coffee grounds
Notes: ascertain quantity and frequency of blood. However, quantity can be difficult to assess because even small amounts (5-10 mls) turn water in a toilet bowl an opaque red; and modest amounts of vomited blood appear huge to an anxious patient in a subacute bleed. Melaena may show itself tomorrow - Syncope/dizziness
- Dyspepsia/epigastric pain
- Weight loss
Key questions
- "Have there been any changes in your tablets in the last 4-6 wks?" esp NSAIDs/warfarin)
- "Have you ever been a heavy drinker (of alcohol)?"
- "Do you feel faint when you sit up?"
Note: ask about other risk factors for liver disease
Signs
- Of hypovolaemia: hypotension = systolic BP < 100 mmHg (lack of, does not exclude significant bleed, see below), tachycardia, sweating, pallor
- Postural hypotension = postural drop >10mmHg
- Urine output <0.5ml/kg/hour
- Stigmata alcohol/liver disease
- Rectal examination is mandatory (melaena?)
- Note: look for rare causes of bleeding (Osler-Weber-Rendu)
4 assessment problems
- Patients do not necessarily drop their Hb acutely. It takes several hours for haemodilution to occur. So, a normal HB does not exclude a significant bleed; and you should not wait for Hb to decide whether to transfuse or not
- Older patients (especially those on rate limiting drugs, eg beta-blockers) cannot produce a tachycardic response to hypovolaemia. They tend to experience hypotension after relatively small losses
- Conversely, younger patients can suffer a major loss before decompensating and dropping BP. Hence a normal BP does not exclude a significant bleed
- A raised urea in the presence of a normal creatinine indicates a significant GI bleed, not renal failure
Investigation
Patients do not necessarily drop their Hb acutely. It takes several hours for haemodilution to occur
Blood
- FBC
- U+E, LFT/GGT, Bone, Glucose ± Amylase (if abdominal pain)
Note: leucocytosis common; platelets increased in subacute bleeding; or decreased in portal hypertension, leading to hypersplenism); urea may be raised, due to protein load - INR, G+S or Cross-match if unwell (2-6 units)
- Liver screen, if appropriate [Ref]
ABG, if unwell
Other
- CXR (gas under diaphragm?; though bleed and perforation rare together)
Key investigations
- FBC
- U+E (urea rises when blood is digested in the GI tract – raised urea with a normal creatinine suggests a significant bleed)
- INR
Specialist investigation
- Endoscopy (identification of cause in >90% and permits treatment); but early endoscopy does not improve mortality
Differential diagnoses
- Lower GI bleed
- Haemoptysis
- Epistaxis (blood swallowed then vomited)
Treatment
Reassess after 4h; it is a dynamic process
Treatment (first line)
Drugs
- IV OMEPRAZOLE 40 mg od (in severe non-variceal bleed);
Note: IV omeprazole only of benefit in those that are high risk (judged after endoscopy, by requiring endoscopic therapy). No firm evidence of benefit pre-endoscopy: [Ref] - IV METOCLOPRAMIDE 10-20 mg stat
- ± TERLIPRESSIN 2 mg IV stat, if variceal bleed suspected (then continue 1-2 mg qds)
- ± IV VITAMIN K 10 mg, slowly/FFP (if variceal bleed suspected or INR >1.3)
- ± Platelets, if clotting abnormalities
Procedures
- Protect the airway
- Insert 2 large bore cannulae
- IV fluids if hypovolaemic (systolic BP < 100 mm Hg or HR > 100); do not wait for the Hb
- Use colloid initially; if only have crystalloid, then use 5% dextrose if liver disease, then:
- Blood (aim for haemoglobin 10 g/dl); in emergency, give O negative blood – Aim to keep systolic BP >100 mmHg but not much higher than this (may increase likelihood of bleeding)
- Watch for signs fluid overload (especially elderly, CRF, CCF)
- Reassess after 4h, or earlier; give FFP, if transfused > 4 units - Nil by mouth, until endoscopy
Prescribing issues
- Stop drugs (below) that may have 'caused' bleed
Key management decisions
- Resuscitate - Transfuse/not
- Endoscopy/not – Indications for urgent endoscopy:
1. Variceal bleed suspected
2. Continued bleeding requiring > 4 units blood to maintain systolic BP > 100mmHg
3. Rebleed after resuscitation
4. Any patient with a ‘Rockall’ pre-OGD score = 2 or more (see table below) - Surgery/not
Stop
- Aspirin
- NSAIDs/warfarin/other anticoagulants
- Antihypertensives
- Diuretics
- Prednisolone?
Treatment (second line)
Procedures
- If unwell, CVP line (maintain at +5 cm H20), urinary catheter (maintain UO > 30 mls/h), arterial line
- ± Sengstaken tube (varices)
- ± Surgery
Admit?
- Usually; but >10% of GI bleeds can go home; if fulfill all low-risk criteria of Glasgow-Blatchford Score (GBS) (see below)
Bed plan
- Ideally gastroenterology ward
- Otherwise medical admission ward
- ± ITU
Referrals
Medical
- Gastroenterology
- ± General surgery
- ± ITU
Other
- Community alcohol service
The Rest
Consider outpatient care, if Pre-endoscopy Rockall Score = 0-1, or a Glasgow-Blatchford Score = 0-1
Maxim
- 'If you don't out your finger in it, you will put your foot in it'
Complications
- Hepatic encephalopathy, if also has chronic liver disease
- ARF (hypovolaemia)
Rockall Score (pre-endoscopy)
Rockall Score (pre-endoscopy): Total maximum score 7. Mortality 0-2 = 0%, 3 = 3%, 4 = 5%, 5 = 11%, 6 = 7%, 7 = 27%; 0-1 consider discharge; 2 or more consider early endoscopy; 3 = senior review ASAP
|
Points |
0 |
1 |
2 |
3 |
|
Age |
<60 |
60-79 |
>80 |
|
|
BP HR |
>100 <100 |
>100 >100 |
<100 |
|
|
Co-morbidity |
|
|
Heart failure Major co-morbidity |
Renal/liver failure Disseminated malignancy |
Glasgow-Blatchford Score
Low-risk criteria of Glasgow-Blatchford Score: if all present (ie GBS 0), can be managed as outpatient:
- Urea <6·5 mmol/L
- Haemoglobin ≥130 g/L (men) or ≥120 g/L (women)
- Systolic blood pressure ≥110 mm Hg
- Pulse <100 beats per min
- Absence of melaena, syncope, cardiac failure, or liver disease
[Ref] and [Ref]
Prognosis
- 80% resolve spontaneously, with no intervention at endoscopy (or surgery)
- Mortality
- 10% mortality
- 30% mortality if >90 yrs
- 30% mortality if rebleed (25%)
- Poor prognostic indicators include: old age, shock, rebleeding, varices, comorbidities (eg CRF, CLD, CCF, COPD), bleeding diathesis, drowsy
2°Prevention + Health Promotion
- Stop NSAIDs, alcohol
- Reconsider warfarin (assess risk:benefit)
Don't forget
- Rectal examination is mandatory
- Reassess after 4h
- PPI and early endoscopy do not reduce mortality
- Good resuscitation might. So, senior review ASAP if unwell, or Rockall Score ≥ 3
- Normal BP does not exclude significant bleed
- Normal Hb (initially) does not exclude significant bleed
- Ring gastro team/surgeons/ITU early, if patient unwell
- Correct coagulation/platelet abnormalities
Red flags
- Rebleeding
- Varices
- Frail/elderly
- Poor prognostic factors (see above)