UPPER GI Bleed BY DR DENNIS PRABHU DAYAL

GI Bleeding Maybe classified into: Upper GI bleeding (proximal to DJ flexure) Variceal bleeding Non-variceal bleeding Lower GI bleeding (distal to DJ flexure) Upper GI bleeding 4 x more common than lower GI bleeding Emergency resuscitation same for upper and lower GI bleeds

Emergency Resuscitation Takes priority over determining the diagnosis/cause ABC (main focus is ‘C’) Oxygen: 15 L Non-rebreath mask 2 large bore cannulae into both ante-cubital fossae Take bloods at same time for FBC, U&E, LFT, Clotting, X match 6 Units Catheterise IVF initially then blood as soon as available (depending on urgency: O-, Group specific, fully X -matched) Monitor response to resuscitation frequently (HR, BP, urine output, level of consciousness, peripheral temperature, CRT) Stop anti-coagulants and correct any clotting derrangement NG tube and aspiration (will help differentiate upper from lower GI bleed) Organise definitive treatment (endoscopic/radiological/surgical)

Estimating Degree of Blood Loss RR, HR, and BP can be used to estimate degree of blood loss/hypovolaemia

History and Examination Aim of history and examination is 3 fold 1. Identify likely source – upper vs lower – and potential cause 2. Determine severity of bleeding 3. Identify precipitants (e. g. Drugs)

History in patients with GI bleeding PC/HPC Duration, frequency, and volume of bleeding (indicate severity of bleeding) Nature of bleeding: will point to source Haematemesis (fresh or coffee ground)/melaena suggest upper GI bleed. (Note a very brisk upper GI bleed can present with dark or bright red blood PR). PR Dark red blood suggests colon PR Bright red blood suggests rectum, anus If PR bleeding, is blood being passed alone or with bowel opening (if alone suggests heavier bleeding) If with bowel opening is blood mixed with the stool (colonic), coating the stool (colonic/rectal), in the toilet water (anal), on wiping (anal) Ask about associated upper or lower GI symptoms that may point to underlying cause E. g. Upper abdominal pain/dyspeptic symptoms suggest upper GI cause such as peptic ulcer E. g. 2. lower abdo pain, bowel symptoms such as diarrhoea or a background of change in bowel habit suggest lower GI cause e. g. Colitis, cancer Previous episodes of bleeding and cause PMH History of any diseases that can result in GI bleeding, e. g. Peptic ulcer disease, diverticular disease, liver disease/cirrhosis Bleeding disorders e. g. haemophilia DH Anti-platelets or anti-coagulants can exacerbate bleeding NSAIDs and steroids may point to PUD SH Alcoholics at risk of liver disease and possible variceal bleeding as a result Smokers at risk of peptic ulcer disease

Upper GI bleeding refers to bleeding from oesophagus, stomach, duodenum (i. e. Proximal to ligmanet of treitz) Bleeding from jejunum/ileum is not common

Presentation Acute Upper GI bleeding presents as: Haematemesis (vomiting of fresh blood) Coffee ground vomit (partially digested blood) Melaena (black tarry stools PR) If bleeding very brisk and severe then can present with red blood PR! If bleeding very slow and occult then can present with iron deficiency anaemia

Risk Stratification: Rockall Score Identifies patients at risk of adverse outcome following acute upper GI bleed Score <3 carries good prognosis Score >8 carries high risk of mortality

Management (Non-variceal) Emergency resuscitation as already described Endoscopy Urgent OGD (within 24 hrs) – diagnostic and therepeutic Treatment administered if active bleeding, visible vessel, adherent blood clot Treatment options include injection (adrenaline), coagulation, clipping If re-bleeds then arrange urgent repeat OGD Pharmacology PPI (infusion) – p. H >6 stabilises clots and reduces risk of re-bleeding following endoscopic haemostasis Tranexamic acid (anti-fibrinolytic) – maybe of benefit (more studies needed) If H pylori positive then for eradication therapy Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids if safe to do so (risk: benefit analysis)

Variceal Bleeds Suspect if upper GI bleed in patient with history of chronic liver disease/cirrhosis or stigmata on clinical examination Liver Cirrhosis results in portal hypertension and development of porto-systemic anastamosis (opening or dilatation of pre-existing vascular channels connecting portal and systemic circulations) Sites of porto-systemic anastamosis include: Oesophagus (P= eosophageal branch of L gastric v, S= oesophageal branch of azygous v) Umbilicus (P= para-umbilical v, S= infeior epigastric v) Retroperitoneal (P= right/middle/left colic v, S= renal/suprarenal/gonadal v) Rectal (P= superior rectal v, S= middle/inferior rectal v) Furthermore, clotting derrangement in those with chronic liver disease can worsen bleeding

Management of Variceal bleeds Emergency resuscitation as already described Drugs Somatostatin/octreotide – vasoconstricts splanchnic circulation and reduces pressure in portal system Terlipressin – vasoconstricts splanchnic circulation and reduces pressure in portal system Propanolol – used only in context of primary prevention (in those found to have varices to reduce risk of first bleed) Endoscopy Band ligation Injection sclerotherapy Balloon tamponade – sengstaken-blakemore tube Rarely used now and usually only as temporary measure if failed endoscopic management Radiological procedure – used if failed medical/endoscopic Mx Selective catheterisation and embolisation of vessels feeding the varices TIPSS procedure: transjugular intrahepatic porto-systemic shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding from varices): performed if failed medical and endoscopic management Can worsen hepatic encephalopathy Surgical porto-systemic shunts (often spleno-renal) Liver transplantation (patients often given TIPP/surgical shunt whilst awaiting this)

TIPSS Sengstaken-Blakemore Tube

Surgical porto-systemic shunt (spleno-renal shunt)

Variceal Bleed: Prognosis closely related to severity of underlying chronic liver disease (Childs-Pugh grading) Child-Pugh classification grades severity of liver disease into A, B, C based on degree of ascites, encephalopathy, bilirubin, albumin, INR Mortality 32% Childs A, 46% Childs B, 79% Childs C

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