Upper GI Bleeding

DEFINITION

Haematemesis
Vomiting of blood, its source usually proximal to the DJ flexure and generally indicating a rapidly bleeding lesion.
Malaena
Passage of tarry black stools, the colour and characteristic smell being due to bacterial degradation of blood which usually originates in the stomach, duodenum or small bowel.

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INCIDENCE
Common
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AETIOLOGY

50% Peptic ulcer disease (mortality <5%)
10% Gastric erosion / stress ulcers
10% Mallory Weiss tear.
10% Oesophageal Varices (mortality 30%).
10% Oesophagitis / Gastritis
1ml/min adds to 1.5L / 24 hrs.

1% Upper GI cancer.
5% Vascular malformations.
Rest: multiple pathologies / other causes.
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BIOLOGICAL BEHAVIOUR

Age and comorbidity are major determinants of prognosis.
75% of PUD bleeds stop spontaneously or with medical intervention.

PUD
Bleeds usually arise on posterior duodenum; can penetrate gastroduodenal artery.
D2 ulcers frequently bleed

Mallory Weiss

1-4cm tear in mucsoa near GJ following vomiting.
- 75% confined to stomach, 20% straddle jx, 5% in distal esophagus.
- many have a hiatal hernia.

Acute Haemorrhagic Gastritis
Often in systemically / critically ill patients due to Curling ulcer type pathophysiology.


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MANIFESTATIONS

Haematemesis / Malaena
- coexistence suggests severe haemorrhage

Haematochezia
Bright red blood PR is possible with profuse bleeding.
May be stable, transient responders, or unstable.

vs Slow Trickle
Chronic anaemia may be only sign

History

Ask:
- what?
- how much?
- faint?
- pud symptoms?
- previous episodes / ulcers?
- liver disease / alcohol?
- family history (common in pud)?
- alcohol and smoking (smoking>alcohol for PUD causation)
- drugs (eg NSAIDs, anticoagulants)?
- aortic surgery (fistula assumed)?
- comorbidities?

Signs
Examine:
- liver disease / scars.
- shock?

Mallory Weiss
Typically forceful retching then blood.
90% stop with ice water gastric lavage.
- sometimes endoscopic intervention, occasionally surgery.

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INVESTIGATIONS

See below.

Bloods
Hb: unreliable for severity.
Urea: urea/creat ratio >100 highly predictive of upper GI cause.

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MANAGEMENT

Pitfalls
More precise blood transfusion, undertransfusion.
Late decision to operate.

Classification

Mild-Mod Bleed
Normal BP & pulse, Hb>100.
Admit, hrly obs.
Drink from outset.
Normal diet within 24hrs.
- once clear evidence no more bleeding.
- repeat Hbs.
- remember to fast pending endoscopy
Think about H.pylori, NSAIDs, acid suppression.

Severe Bleed
Pulse >100, BP<100sys, Hb<100, Age>60
Most have significant comorbidity.
Admit ICU
2 large leurs
Monitor closely
Catheterise if reqd.
Early endoscopy

Resuscitation
ABC.
O2
Large bore cannulae
- (preferably 2, but don't delay resuscitation to gain second)
- blue = 31ml/min; pink 55, green 90, gray 170, orange 275.
- X-match 4-6units
- LFGS, U&Es, PR.
Volume restoration
IV fluids, catheter as appropriate
- cautious resuscitation, controlled hypotension.
Haemodynamic stabilisation
In 70-80% bleeding will stop spontaneously
Want Hb 100-110.
If >3units blood reqd
-->  surgical consideration needed.
- or if suspected perf / ongoing bleeding.
Coagulopathic correction.
If INR>1.5:
- FFP x2 units may be reqd.
- rarely plasma reqd.
What if they are on dabigatran?
Won't wear off for 24 hrs, at least.
If renal impairment, make than 72.

Endoscopy
Ideally within 24 hrs, especially in high-risk pts.
-
earlier if hypotension persisting / large volume.
Stigma of ongoing risk:
- active pulsatile bleeding (high risk)
- visible vessel / clot
- ongoing oozing (lower risk)
- varices or cancer
--> surgical consideration needed; high risk of rebleed (Greath)
Reasonable to defer biopsy in presence of active bleeding.
If endoscopy normal, consider haemobilia.
Treatment
Control bleeding; residual oozing is a worry.
Adrenaline injection or thermocoagulation reduces rebleed risk by 50%.
- 20% will still rebleed within 72hrs.

Indications for PUD Repair
Exsanguinating haemorrhage that can't be controlled endoscopically (<10%).
Initial sentinel bleed is controlled, but subsequently have a further bleed.
Risk of not operating becomes greater than risk of operating in these situations:

<60 years, no comorbidities.

2 re-bleeds.
OR >6 units of blood in any 24 hour period.
OR >12 units of blood total.

>60 years, comorbidities.

1 re-bleed (may attempt endoscopic control first again, perhaps in theatre)
OR >4 units of blood in any 24 hour period.
OR >8 units of blood total.

Which operation?

Primary goal is to stop bleeding.
Secondary goal is to prevent rebleeding.

Gastric ulcer surgery
As for perforation - localized excisions
If bleeding site unknown (no prior endoscopy):
- anterior gastrotomy and find source
- in very rare instances, ligation of gastric blood supply (except short gastrics) or even near-total gastrectomy warranted; high mortality.

DU Surgery
May simply under-run the bleeding point and manage on medical therapy.
May need to excise ulcer and close defect.

Drug Therapy

Omeprazole
Theory

Protects the clot rather than helping the ulcer.
Stability of clot is reduced in an acid environment.
- ph>6 needed for platelet aggregation
- clot lysis occurs in pH<5.
Daneshmend et al originally conducted a placebo-controlled RCT, showed no benefit.
- however flawed by heterogenous inclusion of varices, tumours, ulcers etc.
2 RCTs have since been done looking at ulcers with visible vessels/clots.
- (Khuroo et al, Lau et al)
- reduces rate of rebleeding (6.7% vs 22.5%)
- less transfusions, hospital stay, endoscopies, operations.
Mild Bleed
Omeprazole 40mg q6hrly po.
- if allowed oral intake.
- may take a day or two to get ph up.
Severe Bleed
Omeprazole 80mg IV stat
40mg q6hrly IV
- given in 100ml N saline over 20-30mins.
(costs $20 a day).
Notes
Omeprazole serum t1/2 1-2hrs
Biological t1/2 72hrs.
Stable infusion form would be best, but not available in NZ.
Second best is IV dosing.

Octreotide
Consider if haemodynamically unstable.
- whether or not varices suspected.
- esp if endoscopy going to be delayed.
50mcg IV stat, then 25 mcg/hr in N saline.

Erythromycin
Consider prior to endoscopy
- encourages gastric emptying.
IV 250mg, 30-60m prior to endoscopy.

Varices
Vigorously correct coagulopathy.
Broad spectrum ABs
Nitrates
Lactulose
Consider early B-blockers.
Sengstaken/Blakemore tube +/- intubation may be necessary.
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REFERENCES
NEJM editorial 343:358-359.
Daneshand et al. BMJ 1992;304:143-7.
Khuroo et al.  Comparison of Omeprazole and Placebo for Bleeding PU.  NEJM 336 : 15 April 97.
Hill J.  Surgical Emergencies.
Lau et al.  NEJM 2000;343:310-16.
Doherty.
Cameron