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:
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.
- Following resuscitation; Endoscopy should be done in patients with acute upper GI bleeding
- FBC- should be regularly monitored for anaemia
- 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
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.
Causes of Upper GI bleeding
- Gastric ulcer/duodenal ulcer
- Oesophagitis/gastritis and erosions
- Oesophageal/gastric varices
- Portal hypertensive gastropathy
- Mallory-weiss Tear
- Vascular malformation (inc Dieulafoy’s lesion)
NB other causes of haematemesis include bleeding from the nasopharyngeal space (epistaxis)