Editing Upper GI bleed

Loss of blood from the alimentary canal proximal to the ligament of Treitz

* 'massive GIB' - haemodynamic instability or transfusion requirement
* 'occult GIB' - anaemia that persists or recurs after negative workup

== '''Epidemiology''' ==

* About 60% of all acute GIT bleeds

== '''Aetiology''' ==

* '''Most commonly EROSIVE (oesophagus, stomach or duodenum) or VARICES'''
** So if varices are not suspected, it's most likely to be erosive
** In liver patients (cirrhosis or portal hypertension), 90% of UGIB are caused by varices
* '''Erosive/ulcerative'''
** Oesophagitis (13%)
*** Chronic exposure to gastric acid leads to an inflammatory response that can result in chronic blood loss, perhaps also with ulcerations
*** Other underlying causes:
**** Infection (candida, HSV, CMV)
**** Crohn disease
**** Radiation
**** Medications (NSAIDs, oral bisphosphonates, tetracyclines)
*** Haematemesis very common, melaena less common
*** Treat with PPI. Endoscopic coagulation is generally successful. Surgery seldom necessary.
** PUD (see separate topic and section below) - about 60% of UGIB
*** 10-15% of patients with PUD will develop bleeding at some point
*** Bleeding ulcers are more frequently associated with NSAIDs than H. pylori, but note that H. pylori tests have reduced sensitivity in bleeding, so this may be an underestimate
*** 75% will stop bleeding with IVF and IV PPI
*** Duodenal ulcers are more likely to stop bleeding spontaneously, and have lower morbidity/mortality rates than gastric ulcers
*** Significant bleeding occurs when the erosion reaches a submucosal artery, or an even larger artery in penetrating ulcers (GDA or LGA)
** Gastritis
*** See separate topic - stress gastritis
** Duodenitis
* '''Complications of portal hypertension'''
** Oesophagogastric varices
*** See separate topic
*** Look for signs of portal hypertension (splenomegaly, thrombocytopaenia, ascites) and stigmata of chronic liver failure (jaundice, palmar erythema, gynaecomastia, spider angiomata, testicular atrophy, Dupuytren's contracture).
*** Often blood in GIT precipitates decompensation in cirrhotics, leading to encephalopathy.
** Ectopic varices
** Portal hypertensive gastropathy
*** Often smaller volume bleeding. Still see signs of portal hypertension/cirrhosis on exam such as splenomegaly.
* '''Vascular lesions'''
** Angiodysplasia
** Dieulafoy's lesion
*** Sudden-onset large volume painless bleeding
*** See separate topic
** Gastric antral vascular ectasia (GAVE syndrome)
*** Collection of dilated venules that appear as a linear red streak converging on the antrum, giving the appearance of a watermelon
*** Associated with cirrhosis/portal HTN, collagen vascular disease (scleroderma), IHD, CKD, pernicious anaemia, and bone marrow transplant recipients
*** Severe haemorrhage is rare, with most patients presenting with persistent iron deficiency anaemia from continued occult blood loss
*** Endoscopic therapy (APC) indicated for persistent anaemia or transfusion-dependent bleeding. Success rate >90%. Typically 2-3 treatments are required, separated every 1-2 months.
*** Consider antrectomy for those that do not respond to endoscopic therapy.
* '''Traumatic/iatrogenic'''
** Mallory-Weiss tears (5-10%)
*** See separate topic
** FB ingestion
** Post-surgical anastomotic bleeding
** Post-instrumentation bleeding
*** Endoscopic sphincterotomy - inject with adrenaline and gold probe
** Aortoenteric fistula
*** Separate topic
** Cameron Lesion
*** Erosions or ulcers occurring in the sac of a hiatal hernia
*** Usually incidental, but can cause bleeding
*** Surgery to repair hiatus hernia can be considered in patients with recurrent bleeding despite conservative management
* '''Tumours'''
** Upper GI tumours such as GIST
*** Usually associated with chronic bleeding rather than acute
*** Often successful in initial control, but with a high rebleeding rate
*** Therefore, resection is indicated when this is diagnosed
**** Palliative: wedge resection
**** Curative: standard oncologic operation
* '''Miscellaneous'''
** Haemosuccus pancreaticus
*** See separate topic
** Haemobilia
*** See separate topic under biliary
** Inflammatory bowel disease
*** Very rare to present as UGIB
*** Can get duodenal ulcer - treat in the usual way
** Swallowed blood (nosebleed)

== '''Aetiology of post-op bleeds:''' ==

* PUD/stress ulcer (more likely with sicker pts)
* M-W tear
* Varices
* Anastomotic
* All other causes still possible

== '''Identifying anatomic location''' ==

* Factors predictive of UGI source
** Pt-reported melena (LR 5)
** Melena on exam (LR 25)
** BUN:serum creat >30 (LR 7.5)
*** This references mg/dL units for both urea and creatinine
*** If using urea in mmol/L and creatinine in micromol/L like in Australia, ratio >0.121 predicts UGI source
** Blood/coffee grounds on NGT (LR 9)
** No blood clots in stool (LR 0.05)
* Imaging
** CTA
*** Sensitivity 100%, specificity 90%
*** Ideally three-phase scan with just IV contrast
*** Can apparently detect bleeds as slow as 0.3mL/min
** Technetium-99-m-labelled RBC scintigraphy
*** Can detect bleeds as slow as 0.04mL/min
* Gastric lavage
** Inject 50mL of saline to the NGT and aspirate
** Bile-stained fluid is fairly sensitive
** If no bile, could be duodenal bleed with pyloric spasm, which happens commonly

== '''Clinical manifestations''' ==

* Melaena
** Malodourous, black, tarry stool
** By-product of haemoglobin degradation by digestive enzymes and intestinal bacterial flora into haematin
** Can occur with as little as 50mL of bleeding
** Generally means proximal to ligament of Treitz (90%), but consider nasopharynx through to right colon as sources
* Haematochezia (usually means lower GI)
* Haematemesis
** Red blood means ongoing/severe
** Generally means proximal to ligament of Treitz
* Don't usually have pain - blood is alkaline and serves as an antacid

== '''Approach to significant UGIB''' ==

=== Resuscitate ===

## ABCD
## 2x IVC + IVF
## Bloods - VBG, FBE, UEC, LFT, coag, x match (aim Hb > 70, or >90 if CAD/active bleeding)
## Antiemetics, analgaesia
## May need to call consultant/OT/anaesthetist/ICU
## Transfuse (once 1L crystalloid has been given) and MTP if needed (EMST - 10 units in 24 hours or 4 units in 1 hour). Give at least 1 unit FFP per 2 units pRBC. In general, stick to standard transfusion targets, but can give more blood early due to unclear true degree of blood loss.
## Sistaken-Blakemore tube if truly unstable (can leave for 36 hours; generally very effective)

=== Initial management for admission ===

## ?ICU
## NBM
## TEDs, no enoxaparin
## IV PPI 80mg BD (leads to fewer Forrest Ia to Iia ulcers on endoscopy)
## Antibiotic prophylaxis in patients with cirrhosis
## May need NGT
## ?IDC
## Stop antihypertensives, anticoagulants and antiplatelets
## Consider correcting coagulopathies
## ?thiamine
## If suspected variceal bleeding (any symptoms or findings suggestive of portal hypertension)  - octreotide - not useful otherwise unless endoscopy unavailable - see below section on varices
## Probably no role for tranexamic acid (HALT-IT trial, 2020 - no benefit to mortality)
## AIMS65 score to predict in-hospital mortality from UGIB

### One point for each of:

#### Albumin <30
#### INR >1.5
#### Altered mental status
#### SBP <90
#### Age >65

### Each point is equally weighted and gives increasing mortality: 1, 5, 10, 15, 25%

## Glasgow-Blatchford score to identify low-risk UGI bleeds

###

## If big bleed, consider gastric lavage prior, or at least having a tube ready

=== Identify cause ===

## Aim endoscopy at 8-24 hours (unless meets indications for immediate endoscopy - below)

### Consider IV metoclopramide 10mg or erythromycin 3mg/kg, 1 hour prior to endoscopy as a prokinetic (erythromycin has more convincing data behind it to reduce need for second-look endoscopy, but metoclopramide is probably better than nothing)
### Consider putting a nasogastric lavage tube on standby if active bleeding and going to endoscopy
### If can't see anything because of blood - try repositioning the patient upright

## Indications for immediate endoscopy:

### Suspected variceal bleeding
### Non-responder or transient responder to resuscitation

## PUD - will need endoscopy. If suspected bleeding ulcer should be within 24 hours. If serious bleeding, 12 hours. Endoscopy within 8 hours can often mean a bad view and worse outcomes! So aim 8-12 hours.
## Oesophagitis/gastritis
## Varices - look for evidence of portal hypertension - see below for specific management

# Post-procedure care

## A conservative approach would be to keep to clear fluids for 48 hours if bleeding was found
## Consider abdo USS to exclude portal vein thrombosis
## Classically an NGT on suction would be used to assess for re-bleeding, but this is unnecessary and causes disproportional discomfort

=== '''Normal gastroscopy - the next step''' ===

* CTA if it is likely to show anything
* If not, prep the patient and do a colonoscopy (35% GIT bleeds from large bowel)
** Can do 'rapid prep' - 4L polyethylene glycol given within a period of 4 hours (NGT), followed by colonoscopy within 1-2 hours
* If colonoscopy is normal, evaluate small bowel (5% of acute GIT bleeds)
** CTA/RBC scan/pillcam/push endoscopy
* Obscure-overt bleeding (no cause after all these investigations, but ongoing) should have a repeat upper and lower endoscopy

== '''Bleeding ulcers''' ==

=== '''Classification:''' ===

**

{| class="wikitable"
|Forrest classification
|Stigmata
|Risk of re-bleeding on medical management
|-
|I a
|Brisk bleeding/spurting
|90%
|-
|I b
|Oozing
|10-20%
|-
|II a
|Non-bleeding visible vessel
|50%
|-
|II b
|Adherent clot
|25-30%
|-
|II c
|Flat pigmentation spot
|5-10%
|-
|III
|Clean-based ulcer
|3-5%
|}

*** Iic ulcer
** Intervene on category I, II a and II b ulcers
** Other high-risk factors - ulcers >2cm, posterior duodenal wall ulcer, lesser gastric curve ulcer

=== '''First-line: endoscopic intervention''' ===

** Wash off adherent clot if present
** inject with ~10mL total of 1:10,000 adrenaline spread between all four quadrants, AND another modality
** Either thermal (gold) probe, haemoclip (IIa ulcers), APC or sclerosant (alcohol) injection
*** Push gold probe into base of ulcer and fire - bleeding is most often caused by an artery in the base, and you can collapse the walls then fire the probe. Fire it a few times.
** Important thing is to use dual modality

=== '''Second-line: embolization''' ===

** If no resolution possible on endoscopy, proceed to transcatheter arterial embolization (TAE) - seems to have equal outcomes with surgery and lower complication rates
** Better for duodenal rather than gastric bleeds
** Especially useful with haemorrhage into biliary tree or pancreatic duct
** Most common bleeding vessel is GDA, left gastric, right gastric, splenic arteries
** Higher rates of re-bleeding from TAE than surgery, but good in high operative risk patients
** Efficacy for UGIB 44-100%
** Previously vasopressin infusion may have been used, but not deployed any more

=== '''Third-line: surgery (needed in 5-10%)''' ===

** Indications:
*** Failed endoscopy x2
*** Haemodynamically unstable despite vigorous resus (>3 units)
**** Previously, >= 6 units in index 24 hrs was indication for surgery
*** Recurrent haemorrhage after haemostasis with endoscopy (reasonable to try twice with endoscopy)
*** Ongoing transfusion requirement >3 units per day
*** Unable to transfuse (rare blood type, refusal of transfusion)
** Technique
*** Upper midline laparotomy (bleeding duodenal ulcers can technically be treated laparoscopically, but difficult)
*** Examine for external signs of ulcer - will often be able to see serosal inflammatory changes at the site of a chronic ulcer
*** If any doubt as to location, use intra-operative gastroscopy
** Duodenal ulcers: intervention will usually be to oversew or ligate bleeding vessel, which is the '''GDA''' at the base of a posterior ulcer

*** May need a Kocher maneuvre to mobilise the duodenum and get manual control
*** Longitudinal duodenotomy/pyloroduodenotomy from pylorus through to anterior wall of D1/D2
*** Remove blood, isolate bleeding
*** Apply pressure and time for anaesthetics to catch up
*** Underrun bleeding vessel with 3-point U-stitch technique of 2/0 Vicryl
**** Careful of CBD - can insert a probe through the ampulla if necessary - although Mosche says he has never heard of it being sutured over
**** Classically need to suture ligate GDA superiorly and inferiorly (12 and 6 o'clock), with another suture at 3 o'clock for transverse pancreatic branch
*** Close the duodenotomy transversely (like a stricturoplasty)
*** Consider vagotomy or other acid-reducing operation, but this is generally unnecessary nowadays

** Gastric ulcers

*** Use the simplest possible operation that will stop the bleeding
*** First gastrotomy and underrun the bleeding ulcer (30% rebleeding risk)
*** Wedge resection may be a good option for greater curvature ulcers, but this gives a 10% rebleeding risk, so distal gastrectomy is favoured
*** Bleeding proximal ulcers near GOJ are quite difficult to manage - proximal or near-total gastrectomy has very high mortality in setting of haemorrhage. Perhaps a distal gastrectomy with a tongue of proximal stomach, or a wedge resection/buttressed oversewing of the ulcer?

=== '''Rebleeding''' ===

** Repeat endoscopy if technically possible. Surgery is better for haemostasis but more complications

=== '''Medical management''' ===

** ICU?
** IIb and above ulcers should stay on IV PPI for 72 hours then can be discharged (can be BD high-dose - no benefit to infusion in most cases)

*** There doesn't appear to be much difference between IV and PO PPI even while still in hospital, but guidelines still recommend staying on IV

** Pause aspirin, clopidogrel, NSAIDs and SSRIs for 24 hours with ulcer bleeding
*** Aspirin can be resumed after 24 hours - rationalise ongoing need (stop it if it was primary prevention, restart for secondary prevention 1-7 days after bleeding cessation in most cases)
*** Clopidogrel can be resumed after three days in patients with stents
*** SSRIs five days
*** COX-2 selective inhibitors combined with PPIs have a low rebleeding risk, so that is an acceptable combination if anti-inflammatories must continue.
** Don't give tranexamic acid
** Clear fluids first 24 hours then normal diet. IIc and below can go straight to normal diet.
** Discharge - IIc and below can go 24 hours after endoscopy. Anyone that needs treatment for a bleeding ulcer should stay for 72 hours.
** All patients must have H. pylori status established and eradicated if present. Once it has been confirmed eradicated, there is no need for long-term PPI as it doesn't decrease the re-bleed risk of 1.3%.

[[Category:UGIS]]
[[Category:Intern education]]