- 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%. Majority are over 65 years or variceal.
- Mortality / morbidity risk factors include: cause of the bleeding particularly varices; advanced age; shock; fresh red blood; low Hb; co-morbid disease; re-bleed; endoscopic findings.
- Endoscopic stigmata that predict re-bleeding, need for surgery and death include active arterial bleeding, adherent clot, non-bleeding but visible vessel, ulcer size and location. Scoring systems exists eg. Rockall (max post-endoscopy score 11); score 8 = mortality 41%.
- Low-risk group who may be managed as outpatient without early endoscopy can be predicted by Glasgow Blatchford score (GBS), or the pre-endoscopic Rockall score.
- GBS of 0 safely allows discharge without endoscopy, although up to half may then not present for OP endoscopy! Note age is not scored.
Stanley A, Ashley D, Dalton H et al. Outpatient management of patients with low-risk upper GI haemorrhage: multicentre validation and prospective evaluation. Lancet 2009;373:42-7. [Reference]
- Resuscitation, ABC including look for orthostatic hypotension etc. Consider transfusion for shock or acute fall in Hb below 7.0 g/dL (below 10.0 if IHD, PVD etc). Also FFP if INR >1.5 and or platelets if low < 50 x 109/L.
- Gastric lavage – of no proven benefit, but NGT may indicate ongoing bleeding.
- Proton pump inhibitor by infusion ie. omeprazole / pantoprazole 80 mg stat and 8 mg/hr for 72 hours. Reduces high-risk stigmata and need for endoscopic therapy if given pre-endoscopy (OR 0.67). Reduces risk of rebleeding, surgery and death in high-risk patients if given after endoscopy (RR 0.4 / 0.43 / 0.41 respectively). Overall cost-effective and safe, and often now used routinely.
Lau J, Leung W, Wu J et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. NEJM 2007; 356:1631- 40. [Reference]
- H2 blocker IV. Cheap, safe but poor ability to consistently maintain a high intragastric pH >6. No evidence for effect in acute bleeding.
- Somatostatin or octreotide reduce rebleeding, need for transfusion and surgery, but with no improvement in mortality. Also not routine.
Endoscopy within first 24 hrs of admission:
- Early endoscopy provides diagnosis, prognosis and allows immediate therapy. Reduces overall LOS. Bleeding source found in over 90%, and most (>80%) will need no more than supportive therapy initially.
- Otherwise may need injection therapy with adrenaline first line for active bleeding +/- other procedure such as second injectate, thermal contact, clips etc.
- Other sclerosants, thrombin, tissue glue, heater probe, multipolar electrocoagulation, laser, mechanical endoclips (haemoclips) are alternatives, as adjuncts or as monotherapy.
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 then use intra-arterial gelatin, springs or tissue adhesive.
Barkun A, Bardou M, Kuipers E et al. International consensus recommendations on the management of patients with non-variceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101-13. [Reference]
Scottish Intercollegiate Guidelines Network (SIGN). Management of acute upper and lower gastrointestinal haemorrhage. Sept 2008. A national clinical guideline. [PDF Reference]