Upper GI Bleeding

Acute upper GI (i.e. from the mouth to the sphincter of Oddi in the 2nd part of the duodenum) is a potentially life-threatening problem which accounts for around 2500 admissions/year in the UK and has an incidence from 47-116/100,000 per year.

It still carries significant mortality (around 10%).

Presentation and important risk factors

  • Haematemesis, coffee-ground vomit, melaena
    • NB Those presenting with frank haematemesis tend to have more severe bleeding than those with just melaena.  Coffee-ground vomit is formed by blood that has oxidised within the stomach and is darkened and thickened.  It usually indicates less severe bleeding that has stopped
  • Abdominal pain (diffuse or epigastric or chest)
  • Features of shock (hypotension, pallor, anaemia) and syncope
  • Any associated features that may pinpoint a cause
    • retching (mallory-weiss tear)
    • weight loss
    • any hepatic signs e.g. jaundice, ascites, stigmata of liver disease
  • Remember to ask about alcohol use and drugs (particularly aspirin/NSAIDs and steroids) 

Blatchford and Rockall Scores

The Blatchford score is used to assess patients before endoscopy to assess risk:

nleed

Any score >1 should really be investigated further with endoscopy.

  • 0-1- patients should have Hb monitored for 12-24 hours; consider oral PPI (omeprazole 80mg) and review drugs that may have caused GI bleed
  • 2-5- monitor Hb and hourly SEWS; consider esomeprazole infusion (80mg) if witnessed significant bleed (alternatively oral PPI) and if there are significant stigmata of liver disease consider starting terlipressin; complete reversal of any anticoagulation; review need for endoscopy after 12-24 hours (next morning)
  • >5- repeat Hb regularly (consider blood transfusion); if witnessed significant bleeding consider IV esomeprazole infusion (80mg) and if there are stigmata of liver disease consider terlipressin; arrange endoscopy ASAP

The rockall score (below) is simpler.  If the initial (Age, shock and comorbidity) score is >0, then endoscopy should be used to investigate further.  Then, a score ❤ has a good prognosis.  A score >8 carries a high risk of mortality.

bleeidng

Investigations

  • Following resuscitation; Endoscopy should be done in patients with acute upper GI bleeding
  • Bloods
    • FBC- should be regularly monitored for anaemia
    • Crossmatch
    • Coagulation- including APTT and INR
    • U&Es to assess hydration/kidney status and LFTs to assess liver function (UGIB can be a consequence of liver disease)
  • Imaging (CXR/AXR) may be done routinely to check for perforation or obstruction, but may not add any other information
    • A CT may identify underlying disease processes e.g. liver disease, cholecystitis, pancreatitis
    • Angiography may also be used to find a potential source for bleeding if none is found on endoscopy

Management

Resuscitation and initial management

  • Resuscitation should be early and aggressive.  2 large bore venflons (orange/grey) should be inserted and fluids prescribed (colloid or crystalloid)
  • Blood transfusion should be given if haemoglobin is <100 and if bleeding is ongoing (<80 if not)

Management of bleeding

  • Dependent on the cause.
  • Endoscopic treatment is often first line.

bleeidng

 

Causes of Upper GI bleeding

  • Gastric ulcer/duodenal ulcer
  • Oesophagitis/gastritis and erosions
  • Oesophageal/gastric varices
  • Portal hypertensive gastropathy
  • Malignancy
  • Mallory-weiss Tear
  • Vascular malformation (inc Dieulafoy’s lesion)

NB other causes of haematemesis include bleeding from the nasopharyngeal space (epistaxis)

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