Upper GI hemorrhage: Lecture Notes

Epidemiology

• Commonest causes: peptic ulcer (35-50%); oesophagitis (20-30%); duodenitis/gastritis/erosions (10-20%); varices (5-12%); Mallory-Weiss tear (2-5%); tumour (2-5%); angiodysplasia (2-3%); aorto-enteric fistula (<1%).
• Mortality 10 – 14% (not changed for over 50 yrs!). Majority are over 60 years.
  • Independent mortality / morbidity risk factors include: cause of the bleeding particularly varices; advanced age; shock; co-morbid disease; re-bleed; endoscopic findings (scoring systems exists eg. Rockall, maximum score postendoscopy 11; score 8 = mortality 41%).
  • Endoscopic stigmata that predict re-bleeding, need for surgery and death include active arterial bleeding, oozing of blood or a non-bleeding but visible vessel.

Management

• Medical therapy
  • Resuscitation, ABC including look for orthostatic hypotension etc. Consider transfusion for shock or acute fall in Hb below 10.0 g/dL. Also FFP if INR >1.5 and or platelets if low < 50 x 109/L
  • Gastric lavage – no proven benefit, but NGT may indicate ongoing bleeding.
  • H2 blocker IV. Cheap, safe but poor ability to consistently maintain a high intragastric pH >6. Some studies claim lower rates of continued bleeding, surgery and death, but none are convincing. Avoid.
  • Proton pump inhibitor by infusion ie. omeprazole 80 mg stat and 8 mg/hr for 72 hours +/- endoscopy. Reduced need for endoscopy, active bleeding if endoscoped and length of stay. Also reduces risk of rebleeding, and need for surgery, but still no all-cause reduction in mortality.

Lau J, Leung W, Wu J et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. NEJM 2007; 356:1631- 40. [Reference]

Lau J, Sung J, Lee k et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. NEJM 2000; 343: 310-16 [Reference]

Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev 2006;1:CD002094. [Reference]

Levine J, Leontiadis G, Sharma V et al. Meta-analysis: the efficacy of intravenous H2-receptor antagonists in bleeding peptic ulcer. Aliment Pharmacol Ther 2002;16:1137-42. [Reference]

• Somatostatin or octreotide reduce re-bleeding, need for transfusion and surgery, but with no improvement in mortality.

Imperiale T, Birgisson S. Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute non-variceal upper gastrointestinal haemorrhage: a meta-analysis. Ann Intern Med 1997; 127:1062-1071 [Reference]

• Endoscopy within first 24 hrs of admission:
  • Early endoscopy provides diagnosis, prognosis and allows immediate therapy. Bleeding source found in over 90%, and most (>80%) will need no more than supportive therapy initially.
  • Otherwise need injection therapy with adrenaline first line for active bleeding +/- sclerosant such as polidocanol. Also is the easiest and cheapest therapy.
  • Heater probe, multipolar electrocoagulation, laser therapy or mechanical endoclips (haemoclips) are alternatives.

Sung J, Tsoi K, Lai L et al. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal haemorrhage bleeding: a meta-analysis. Gut 2007;56:1364-73. [Reference]

• Surgery / angiography:
  • Surgery if endoscopy fails, and for high risk of re-bleed in the elderly.
  • Angiography for severe, persistent bleeding in high risk patient unsuitable for surgery. May use intra-arterial gelatin, springs or tissue adhesive.

Jairath V, Langmead L. Acute gastroenterology. Clin Med 2007;7:262-6. [Reference]

Westhoff J, Holt K. Gastrointestinal bleeding: An evidence-based ED approach to risk stratification. Emergency Medicine Practice: An Evidence based Approach to Emergency Medicine 2004; 6(3): 1-20. [Reference]

Barkun A, Bardou M, Marshall JK. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2003;139:843-57. [Reference]