Slides from my talk on upper gastrointestinal bleeding for nurses undertaking the Gastroenterology course

1. Upper Gastrointestinal Bleeding
– what to do…
Dr Chris Roseveare
Consultant Physician
Southampton University Hospitals NHS Trust

2. What to do….
 Resuscitate
 Endoscope
 If all else fails – call a surgeon

3. Introduction
 7-8% mortality overall
 26-44% mortality if already hospitalised

4. Poor prognostic factors…
 Older age
 >60 – OR: 1.8-3
 >75 – OR: 4-12
 Co-morbidities
 Cardiac failure - OR: 1.8
 Malignancy - OR: 3.8
 Initial shock - OR: 3.8
 Haematemesis at presentation - OR: 2

5. Acute UGI Bleeding unit
Patient Group
(n=900)
SMR 95% conf
interval
All 0.63 0.48-0.78
Low risk
(Rockall 0-3)
0.35 0.00-1.04
Medium risk
(Rockall 4-6)
0.56 0.34-0.78
High risk
(Rockall >7)
0.7 0.49-0.91
Sanders et al. Eur J Gast Hep 2004, 16(5) 487-94

6. Is the patient shocked?
Class I Class II Class III Class IV
Vol loss
(ml)
<750 750-1500 1500-2000 >2000
Vol loss
(%)
0-15 15-30 30-40 >40
Systolic Normal Normal Low V Low
Diastolic Normal Raised Low V Low
Pulse Slight
tachy
100-120 120 thready >120, v
thready
Resp rate Normal Normal >20 >20
Mental
state
Alert Anxious /
aggressive
Drowsy Confused /
unconsciou
s

7. What size cannula?

8. Jean Louis Poiseuille (1799 - 1869)

9. What size cannula?

10. Flow Rates through Cannulae (ml/min)
Colour Gauge Flow rate (ml/min)
Pink 20 40
Green 18 75
Grey 16 150
Orange 14 300
Triple lumen CVP
line
16 50
What size cannula?

11.  Consider CVP line if:
 Large volume bleed
 Coexistent renal / cardiac failure
 Persistent hypotension / tachycardia
 Suspected / proven varices
Resuscitation

12. What fluid replacement?
 Blood if >30% volume loss
 ?O-negative
 ?Group specific
 ?Cross-matched

13. Crystalloid or colloid?
 No comparative studies in UGIB
 Probably makes no difference

14. Could it be varices?
 Any upper GI bleed with:
 Previous history of varices / variceal bleed
 Clinical evidence of chronic liver disease or
portal hypertension
NB: most ‘alcoholics’ with GI bleeds do not
have chronic liver disease (or varices)

15. Could it be varices?
 Yes……….
 Consider airway protection
High risk of aspiration with high mortality

16. Could it be varices?
 Yes……….
 Reconsider CVP line (if not already)
Avoid over-transfusion

17. Could it be varices?
 Yes……….
 Correct clotting and platelets

18. Could it be varices?
 Yes……….
 Commence Terlipressin 2mg 6 hourly
Superior to endoscopic sclerotherapy in
Bleeding control (Cochrane 2002)
20% reduction in 5 day bleeding control
When combined with endoscopic therapy

19. Could it be varices?
 Yes……….
 Endoscopy at earliest opportunity
It’s not always varices

21. Could it be varices?
 Yes……….
 Endoscopy at earliest opportunity
Enables endoscopic therapy

24. Could it be varices?
 Yes……….
 Consider Sengstaken-Blakemore tube
Reconsider airway protection
May be safer to transfuse and await endoscopist

25. What’s the diagnosis?
An 80 year-old woman is brought to
hospital having collapsed in her home.
On arrival of the ambulance she was
hypotensive, grey and sweaty.
The ambulance crew reported ‘coffee
ground vomit’ while en-route.

26. What’s the diagnosis?

27. What is ‘coffee grounds’?

28. A B
C D

29. What is ‘coffee grounds’?

30. Think….
 Is the degree of haemodynamic
compromise consistent with volume of
reported blood loss?
 Beware a shocked patient with ‘dark’
vomit
 look for an alternative explanation for
hypotension.

31. Why endoscope?
 Diagnose
 Treat
 Risk stratification

32. Endoscopic diagnosis…
Diagnosis Approx %
Peptic Ulcer 44
Oesophagitis 28
Gastritis / erosions 26
Duodenitis / erosions 15
Varices 13
Mallory-weiss Tear 5
Malignancy 5
Vascular Malformations 3

34. Why endoscope a patient?
 Therapeutic
 Stop bleeding

37. Why endoscope a patient?
 Therapeutic
 prevent rebleed

38. Why endoscope a patient?
 Therapeutic
 prevent rebleed

39. Risk Stratification
 Calculation of full Rockall Score

40. Rockall Score
0 1 2 3
Age <60 60-79 >=80
Shock Systolic >100
Pulse <100
Systolic >100
Pulse >100
Systolic <100
Comorbidity None Heart Failure
IHD
Major
Comorb
Renal failure
Liver Failure
Diss Malig.
Diagnosis M-W Tear or
No lesion
All other
diagnoses
Upper GI
malignancy
Bleeding
stigmata
None or dark
spot only
Other
stigmata

41. Rockall Score
0
5
10
15
20
25
30
35
40
45
0 1 2 3 4 5 6 7 8+
Rebleed
Mortality
Score
Per cent

42. When to endoscope?
 Too soon?
 Inadequate resuscitation: higher risk
 Poor views (blood in the way)
 Aspiration (stomach full of blood)

43. When to endoscope?
 Too late?
 Ongoing bleeding
 Rebleeding
 Delay to surgery

44. When to endoscope?
 ASAP if:
 Evidence of ongoing bleeding
 Suspected varices
 Suspected early rebleed
 Otherwise within 12 hrs is usually OK

45. What about IV PPI?
 Clots more stable when pH >4
 Clot lysis occurs when pH <4

46. What about IV PPI?
 Omeprazole 80mg IV bolus followed by 8mg/hour
infusion for 72 hours reduced early rebleed rate (5 vs
24 rebleeds with placebo, p<0.001)
 In patients with endoscopically proven
peptic ulcer with stigmata of haemorrhage
Lau et al. NEJM 2000;343:310-6

47. What about IV PPI?
Limited evidence for
‘empirical’ use of IV PPI
prior to endoscopic
diagnosis in unselected patients

48. What if the patient rebleeds?
 Repeat endoscopy
 Radiological embolisation
 Surgery

49. Repeat Endoscopy
 No difference in bleeding control between
surgery and second endoscopic treatment
 30 day mortality and transfusion requirements
similar
 More complications in group randomised to
surgery
Lau et al N Engl J Med 1999;340:751-756

50. Radiological Embolisation
 Equally effective to surgery as
measured by:

Rates of re-bleeding

Rates of mortality
Ripoll et al J Vasc Interv Radiol 2004; 15:447-450

51. What about surgery?
 >65 with one ‘rebleed’ or > 4 units blood
required for fluid resuscitation
 <65 with 2 rebleeds or >8 units blood
required for fluid resuscitation

52. What about Surgery?
 Dependent on:
 Type of lesion
 Site of lesion
 Co-morbidities
 Likelihood of continued bleeding

53. Summary
 Resuscitate adequately
 Exclude varices (and non-GI source of
shock)
 Endoscopy within 12 hours if non-
variceal
 Intravenous PPI infusion if peptic ulcer
bleed with stigmata of haemorrhage