Upper gastrointestinal bleeding
From Ganfyd
Contents |
Presentation
Acute
Chronic
- Asymptomatic, i.e. incidental anaemia
Treatment
Endoscopy can be diagnostic and therapeutic.
Resuscitation
An exsanguinating patient needs resuscitation more than a clever diagnosis.
- ABC
- Oxygen, especially if signs of hypoperfusion or shock
- i.v. access. Ideally 2 large bore peripheral venous cannulae, or a short, fat "trauma line" into a central vein.
- Cross-match blood, baseline clotting can be useful
- Crystalloid vs colloid vs blood
Causes
- Peptic ulcer disease
- Gastric ulcer
- Duodenal ulcer
- Gastritis
- Mallory-Weiss tears
- Dieulafoy
- Malignant ulcer
- Oesophageal varices
Role of Proton Pump Inhibitors
Pre-endoscopy, a 2006 Cochrane review suggests that these have little role in management.[1]
Post-endoscopy, their use is controversial. Where used, it is unclear if there is any advantage to using continuous high dose PPI, which is based based on idea that clot stability better at higher pH.[2][3][4][5][6][7] Meta-analysis in [8]. Oriental subjects are known to be more sensitive to the effects of proton-pump inhibitors. A recent randomized-controlled trial suggests that the Hong Kong protocol may be no better than once-daily administratin of intravenous 40mg omeprazole.[9]
Prognosis
Glasgow-Blatchford score
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First developed in 2000 as a clinical stratifying score in acute upper gastrointestinal bleeding. Five studies have validated the use of a score of 0 at first presentation as low risk patients suitable for consideration of outpatient management[10][11][12][13][14][15]. It has now been demonstrated in British practice to be superior to the Rockall score in determining who is safe to discharge home and be managed as an outpatient setting which may be about 15% of such presentations[16]. It is also somewhat superior to the Rockall score in predicting who will not need a hospital based intervention for their pathology related to the haemorrhage. However it is not as good as the Rockall score in predicting overall mortality of all who present with a upper gastrointestinal bleed.
Rockall's score
Score that predicts poor prognosis, i.e. death, from upper GI haemorrhage. The original study[17] has been validated by other groups.[18]
| Parameter | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Age | <60 | 60-79 | ≥80 | |
| Shock | None BP >100 HR <100 | BP >100 HR <100 | BP <100 | |
| Co-morbidity | No major | CCF, IHD | Renal or liver failure | Metastatic malignancy |
| Diagnosis | M-W tears, no lesion | All other diagnoses | Upper GI malignancy | |
| Signs of Recent Bleed | None or dark red spot | Blood in upper gut Adherent clot Visible vessel |
Based on the original paper, mortality increases with score:
| Score | Mortality No rebleed | Mortality Rebleed |
|---|---|---|
| 3 | 2% | 10% |
| 4 | 4% | 16% |
| 5 | 8% | 23% |
| 6 | 10% | 33% |
| 7 | 15% | 43% |
| 8+ | 28% | 53% |
Forest classification
- Certain endoscopic stigmata predicting rebleed :[19]
- Ia - Spurting haemorrhage 80–90%
- Ib - Oozing haemorrhage 10–30%
- IIa - Visible haemorrhage 50–60%
- IIb - Adherent clot 25–35%
- IIc - Black spot 0–8%
- III - Clean ulcer base 0–12%
Indications for Surgery
Failure of conservative or endoscopic treatment.
References
- ↑ Dorward S, Sreedharan A, Leontiadis GI, Howden CW, Moayyedi P, Forman D. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane database of systematic reviews (Online). 2006; (4):CD005415.(Epub) (Link to article – subscription may be required.)
- ↑ Daneshmend TK, Hawkey CJ, Langman MJ, Logan RF, Long RG, Walt RP. Omeprazole versus placebo for acute upper gastrointestinal bleeding: randomised double blind controlled trial. BMJ (Clinical research ed.). 1992 Jan 18; 304(6820):143-7.
- ↑ Lau JY, Sung JJ, Lee KK, Yung MY, Wong SK, Wu JC, Chan FK, Ng EK, You JH, Lee CW, Chan AC, Chung SC. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. The New England journal of medicine. 2000 Aug 3; 343(5):310-6.
- ↑ Udd M, Miettinen P, Palmu A, Heikkinen M, Janatuinen E, Pasanen P, Tarvainen R, Kairaluoma MV, Lohman M, Mustonen H, Julkunen R. Regular-dose versus high-dose omeprazole in peptic ulcer bleeding: a prospective randomized double-blind study. Scandinavian journal of gastroenterology. 2001 Dec; 36(12):1332-8.
- ↑ Lee KK, You JH, Wong IC, Kwong SK, Lau JY, Chan TY, Lau JT, Leung WY, Sung JJ, Chung SS. Cost-effectiveness analysis of high-dose omeprazole infusion as adjuvant therapy to endoscopic treatment of bleeding peptic ulcer. Gastrointestinal endoscopy. 2003 Feb; 57(2):160-4.(Link to article – subscription may be required.)
- ↑ Beales IL. Non-variceal upper gastrointestinal haemorrhage. Gut. 2003 Apr; 52(4):609.
- ↑ Proton pump inhibitors for acute upper GI bleeding. Drug and Therapeutics Bulletin 2004;42:41-43. (Link to article - may require subscription)
- ↑ Leontiadis GI, Sharma VK, Howden CW. Systematic review and meta-analysis of proton pump inhibitor therapy in peptic ulcer bleeding. BMJ (Clinical research ed.). 2005 Mar 12; 330(7491):568.(Link to article – subscription may be required.)
- ↑ Andriulli A, Loperfido S, Focareta R, Leo P, Fornari F, Garripoli A, Tonti P, Peyre S, Spadaccini A, Marmo R, Merla A, Caroli A, Forte GB, Belmonte A, Aragona G, Imperiali G, Forte F, Monica F, Caruso N, Perri F. High- versus low-dose proton pump inhibitors after endoscopic hemostasis in patients with peptic ulcer bleeding: a multicentre, randomized study. The American journal of gastroenterology. 2008 Dec; 103(12):3011-8.(Link to article – subscription may be required.)
- ↑ Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000 Oct 14; 356(9238):1318-21.(Link to article – subscription may be required.)
- ↑ Gralnek IM, Dulai GS. Incremental value of upper endoscopy for triage of patients with acute non-variceal upper-GI hemorrhage. Gastrointestinal endoscopy. 2004 Jul; 60(1):9-14.
- ↑ Romagnuolo J, Barkun AN, Enns R, Armstrong D, Gregor J. Simple clinical predictors may obviate urgent endoscopy in selected patients with nonvariceal upper gastrointestinal tract bleeding. Archives of internal medicine. 2007 Feb 12; 167(3):265-70.(Link to article – subscription may be required.)
- ↑ Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. The American journal of emergency medicine. 2007 Sep; 25(7):774-9.(Link to article – subscription may be required.)
- ↑ Masaoka T, Suzuki H, Hori S, Aikawa N, Hibi T. Blatchford scoring system is a useful scoring system for detecting patients with upper gastrointestinal bleeding who do not need endoscopic intervention. Journal of gastroenterology and hepatology. 2007 Sep; 22(9):1404-8.(Link to article – subscription may be required.)
- ↑ Stanley A, Ashley D, Dalton H, Mowat C, Gaya D, Thompson E, Warshow U, Groome M, Cahill A, Benson G, Blatchford O, Murray W. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet. 2008 Dec 15.(Epub ahead of print) (Link to article – subscription may be required.)
- ↑ Stanley A, Ashley D, Dalton H, Mowat C, Gaya D, Thompson E, Warshow U, Groome M, Cahill A, Benson G, Blatchford O, Murray W. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet. 2008 Dec 15.(Epub ahead of print) (Link to article – subscription may be required.)
- ↑ Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996 Mar; 38(3):316-21.
- ↑ Vreeburg EM, Terwee CB, Snel P, Rauws EA, Bartelsman JF, Meulen JH, Tytgat GN. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut. 1999 Mar; 44(3):331-5.
- ↑ Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet. 1974 Aug 17; 2(7877):394-7.
