Upper GI Bleed

James PeerlessApril 2011

Introduction

• Incidence of 100/100 000 population per year (UK & USA)

• >80% occur as acute admissions• ‘Hospital-acquired’– Critically ill patients– Prolonged NG tube– Drug Rx

• Associated with high rate of mortality and long ICU stay

Objectives

• Definitions• Anatomy• Sources of Bleeding• Presentation• Assessment• Management

DefinitionsUpper GI TractThe oral cavity, pharynx, oesophagus, stomach & proximal duodenum

HaematemesisThe act of vomitting blood; swallowed or that arisen from the bleeding within the upper GI tract

MelaenaBlack discoloured faeces due to the presence of partly-digested blood from the upper GI tract

Anatomy

Hepatic a.

Left gastric a.

Right gastric a.Left gastro-epiploic a.

Right gastro-epiploic a.

Splenic a.

Coeliac trunk

Azygous v.

L + R gastric vv.

Portal v.

Causes

Varices

• Secondary to portal hypertension

• Dilated collateral veins formed at G-Oe junction

• These portosystemic anastomoses are superficial and prone to rupture

• High pressure veins in a hyperdynamic circulation

Presentation

• Active bleeding• History of haematemesis• Melaena• Shock/hypotension/collapse• Anaemia

Acute Management

Supportive

• Resuscitation– A B C

• History & Examination• Recruit help• Investigations• Continuous monitoring• Blood products• Correction of coagulopathy

Corrective

• Medical• Balloon tamponade• Endoscopy• Surgical

Assessment

• Acute Assessment• History & Examination• Is the airway safe?• Is the patient at risk of further events?

Identifying Risk

• Rockall Score

Rockall Criteria

Rockall Score0 1 2 3

Age <60 60-79 >80

Shock No shock HR >100 HR >100, SBP <100

Comorbidity Cardiac failure, ischaemic heart disease

Renal failure, liver failure, disseminated malignancy

Diagnosis Mallory Weiss, no lesion, no stigmata of recent haemorrhage

All other diagnoses

Malignancy of upper gastrointestinal tract

SRH (Endoscopy)

None, or dark spot

Fresh blood, adherent clot, visible or spurting vessel

Mortality Rates0 1 2 3 4 5 6 7 8+

Total (%) 4.9 9.5 11.4 15.0 17.9 15.3 10.6 9.0 6.4

Re-bleed (%)

4.9 3.4 5.3 11.2 14.1 24.1 32.9 43.8 41.8

Death (non re-bleed) (%)

0 0 0.3 2.0 3.5 8.1 9.5 14.9 28.1

Death (re-bleed) (%)

0 0 0 10.0 15.8 22.9 33.3 43.4 52.5

Death (total) (%)

0 0 0.2 2.9 5.3 10.8 17.3 27.0 41.1

Rockall TA, Logan RF, Devlin HB, Northfield TC (1996) Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38:316 – 21

Scoring Systems

• Rockall Score• Forrest Classification– Active haemorrhage– Signs of recent haemorrhage– Lesions without active bleeding

• Glasgow-Blatchford Score– Scored on Hb, urea, BP,

presentation/comorbidities (no endoscopy)

Management Pathway

Oesophagogastroduodenoscopy

• Offers diagnostic information and opportunity for therapeutic intervention

• Scoping within 24 hours has a proven reduction in rebleed, mortality and length of admission

• For ulcers:– Adrenaline injection (temporary efect)– Diathermy/haemocoagulation– Endocscopic clips

Variceal Bleeding

• Endoscopy is the definitive treatment of choice for variceal bleed

Drugs & Secondary MX

Sengstaken-Blakemore Tube

Sengstaken-Blakemore Tube

Linton-Nachlas Tube

TIPSS

• Transjugular Intrahepatic Portosystemic Shunt• Radiologically guided stent– Drilled through the liver and connects the portal

and hepatic vein• Available in specialised units• Complications– Thrombosis (10%)– Bleeding– Infarction

Summary

• Hidden clinical picture• Supportive and Corrective Management• Endoscopic therapy mainstay of treatment• Risk of rebleeding remains high – keep

monitoring the patient!

The End