Upper GI Bleeding
The incidence of gastrointestinal hemorrhage ranges from 50 to 150 per 100 000 population each year. Reported mortality rates range from 11% to 33% for patients admitted primarily due to GI hemorrhage or who developed it as a complication of their hospital stay respectively.
Rapid evaluation of the patient for evidence of hemodynamic compromise as well as risk factors for serious hemorrhage is crucial to enable early resuscitation and involvement of interventional services when indicated.
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- Assess for clinical evidence of hypovolemic shock (↑HR, ↓Pulse Pressure, ↓BP (beware compensation) ↑RR, ↑Cap refill, Cold clammy skin, ↓Urine Output, ↑Agitation /Confusion).
- Mild / Moderate / Severe hypovolaemia is respectively indicated by resting tachycardia / Orthostatic Hypotension / Supine Hypotension and equates to approximately 15%, 30% and over 40% loss of total circulating blood volume (5L in 70kg male).
Relevance of History
- Alcohol Abuse, previous GI bleed, liver disease or other causes of abnormal coagulopathy which may require correction / replacement.
- Presence of significant or unstable coronary artery disease or renal disease which may place patients at risk of volume overload during resuscitation attempts.
- Melena on patient history -> Likelihood ratio (LR) of an upper GI Bleed = 5.1-5.9. Examination of stool may give a clue for location of bleeding but is not a reliable indicator. If melena present on PR, LR of UGI bleed is 25. Melena may be seen with as little as 50mls of blood loss. Red stool / altered blood in stool has 11% chance of being Upper GI in origin. When abdominal pain is present, consideration should be given to the possibility of perforation and need for early surgical intervention.
- Anticoagulants / Antiplatelet / NSAIDs / Aspirin / Steroids / Iron supplements.
- These need to be factored into the assessment and/or require treatment / product replacement.
Acute bleeding may not be reflected in the FBC due to ~ 24hrs delay in fluid equilibration. Microcytic changes will only be present if the bleeding / iron deficiency has been chronic. Remember that excessive crystalloid resuscitation may result in the false lowering of the haemoglobin. BUN/Creatinine ratio also positively correlated with UGI Bleeding with ratios >30 having a LR of 7.5.
Peptic Ulcer Disease
|Mallory Weiss tear
Other / Rare
Although gastro-oesophageal varices are less common, managing the underlying liver disease and the severity of bleeding may be more demanding of resources.
Risk Scoring Systems
It is increasingly recognized that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not.
The Glasgow Blatchford Score (GBS)
- Is the most relevant score for the purposes of Emergency management as it can be calculated prior to endoscopy
- It was developed in 2000 to predict the need for hospital based intervention (transfusion, endoscopic therapy, or surgery) or death following UGIH.
- It predicts the need for inpatient care for the purposes of endoscopy and transfusion.
- Six recent studies from United Kingdom and Taiwan have shown the GBS to be superior to the admission Rockall score in predicting need for clinical intervention or death. The GBS has also been shown to be superior to both the full and admission Rockall scores in predicting need for transfusion.
Patients with a GBS score of 0 may be suitable for discharge.
Higher risk groups require in-patient endoscopy for full evaluation and therapy
NP oxygen, monitoring as appropriate based on patients comorbidities / risk of bleeding,
2 x large bore IVCs,
arterial line consideration for high risk patients
NBM in view of potential for endoscopy / interventional procedure
Resus bed if indicated
Early notification of theatres and specialty teams of the likely need for operative management for high risk patients.
Adequate but judicious fluid resuscitation to treat symptomatic hypotension with isotonic crystalloid in 500ml aliquots whilst awaiting appropriately cross-matched blood.
Beware overaggressive crystalloid administration and the potential for hyperchloraemic acidosis if too much “Normal” Saline is given.
Aim for trauma style avoidance of over resuscitation with crystalloids.
The initial resuscitation section recommends haemostatic blood product resuscitation for unstable patients in line with massive transfusion practice in trauma - with the ratio of blood products Packed Cells : FFP : Platelets recommended to be 1:1:1. However where the patient is sufficiently stable to await the pathology results, current guidelines and evidence suggest restrictive transfusion strategies especially in patients with known or suspected variceal disease. Transfuse only for:
Haemodynamic instability despite crystalloid resuscitation
Also give fresh frozen plasma for INR >1.5; give platelets for thrombocytopenia (aim platelets >50 x 109/L).
In the bleeding patient always remember that “cold doesn’t clot” and it is much easier to prevent hypothermia than reverse it. To maintain normothermia, avoid exposure, use a blood warmer for all products and consider a bair hugger early.
Avoid acidosis and ensure adequate ionised calcium levels are maintained, ie above 1.13mmol/L by giving calcium gluconate 2.2mmol (10ml) peripherally IV over 10minutes.
Other medical treatments
Proton Pump Inhibitor eg pantoprazole 80mg IV stat and 8mg/hr infusion for 72 hours. PPI reduces need for intervention during endoscopy (OR 0.67) if given beforehand as well as reducing the incidence of re-bleeding but no evidence of change in mortality. Evidence shows that there is no difference in outcome between 80mg IV BD vs continuous PPI infusion, however, there is a lack of consensus amongst gastroenterologists and emergency physicians.
Give 300mg of Thiamine IVI if there is a question of alcohol abuse
Variceal Bleeding Interventions
Treatment specific to suspected Variceal Bleeding
Each episode of active variceal haemorrhage is associated with 30 percent mortality (UTD). Variceal bleeding stops spontaneously in over 50 percent of patients, but the mortality rate approaches 70 to 80 percent in those with continued bleeding.
Specific to variceal haemorrhage resuscitation is the need to avoid over-transfusion in the initial management of these patients as well as ensuring rapid consideration and correction of any coagulopathies.
Medical therapy aims at reducing the portal venous pressures and so reducing bleeding.
Early Vasoactive therapy should be commenced as promptly as possible on presentation of the patient who has known or suspected varices and should not be held pending confirmation of the diagnosis. Vasoactive medications have been shown to significantly decrease mortality and improve haemostasis in patients with acute variceal bleeding. (There is also some evidence to indicate their efficacy in non-variceal bleeding.)
- Terlipressin 2 mg IV every four hours initially and then once haemorrhage is controlled, can be titrated down to 1 mg IV every four hours; or
- Octreotide 50mcg Bolus followed by 50mcg/hr infusion for 5 days; or
- Somatostatin 250mcg IV Bolus followed by 250mcg/hr infusion.
Antibiotics are indicated in variceal bleeding eg Ceftriaxone 1g IV (this decreases mortality in patients by reducing infections during ICU admissions). More information on antibiotics can be found on eTG complete (institution or subscription access required)
Endoscopy is first line in variceal disease for diagnosis and intervention with potential banding or injection and decreases the risk of rebleeding to approximately 30 percent
Surgical intervention has little role in the management of varices and patients who do not respond to endoscopic therapies are best treated by Transjugular Intrahepatic Portosystemic Shunt (TIPSS).
Specifically, if the location of the varices is known;
- Oesophageal varices:
- Acute bleeding is typically managed with endoscopic variceal ligation within 12 hours (occasionally endoscopic sclerotherapy is used).
- If the bleeding cannot be controlled endoscopically, transjugular intrahepatic portosystemic shunt (TIPS) placement or surgical shunting should be considered.
- Gastric varices:
- Treatment is with tissue adhesives (cyanoacrylate injection) where available
- If cyanoacrylate injection is not an option, TIPS placement is typically used.
- Bleeding ectopic varices may be managed with TIPS placement or surgery.
A guide to intubating the patient with a massive variceal bleed can be found here.
After intubation, Balloon tamponade is an option of last resort to temporarily stop bleeding from oesophageal or gastric varices while definitive treatment is being arranged, but it is associated with serious complications including oesophageal rupture – so always remember to confirm placement of the gastric balloon before you fully inflate it. Confirmation of placement is by listening over the stomach and lungs injecting air into the stomach port, and then inflating 50 mls of air or saline and doing X-ray top confirm in the stomach.
There are 3 types of tubes used for balloon tamponade. This video (EMRAP) provides an excellent overview.
1. Sengstaken-Blakemore tube - 3 ports (2 for filling the balloons with air, and 1 for gastric suction)
- 250cc gastric balloon, an oesophageal balloon, and a single gastric suction port
2. Minnesota tube – 4 ports (just a modified Sengstaken-Blakemore tube)
- Also has an oesophageal suction port above the oesophageal balloon
3. Linton-Nachlas tube – 1 port
- Which has a single, but larger 600cc, gastric balloon
An excellent blog entry on EMCrit here describes placement and has a downloadable pdf of a quick guide .
Remember that Balloon tamponade should only be considered as an interim and dire measure pending endoscopy or where endoscopy has failed and the patient is awaiting TIPS. More information on how to attempt balloon tamponade can be found here.
Long term, the administration of a nonselective beta blocker such as propranolol can also decrease the risk of rebleeding in variceal bleeders.
Non-Variceal Bleeding Interventions
Endoscopy is considered the gold standard for diagnosis and intervention. Endoscopy is recommended within 24 hours of presentation for the diagnosis and treatment of active UGI bleeding and for the prevention of recurrent bleeding rather than waiting more than 24 hours.
Where endoscopy is not available, some evidence suggests that the use of Somatostatin and its long-acting analogue Octreotide may be of benefit even in non-variceal upper GI bleeding. Studies have used standard dosing for Somatostatin but the Octreotide infusion, after a 50mcg bolus, to be administered at half-rate of 25mcg/hr.
For patients who endoscopy has failed or is contraindicated, the options include:
- Should be considered before surgery - local resources and expertise permitting
- Emergency surgery is undertaken for uncontrolled bleeding or re-bleeding that cannot be controlled by further endoscopic therapy and / or where angiography expertise is not available.
- Surgery is also considered in cases of perforation, haemodynamic shock associated with recurrent haemorrhage or ongoing hemodynamic instability despite vigorous resuscitation (more than a three unit transfusion).
- Emergency surgery has a high (36%) mortality rate whilst “early elective surgery” has a much lower mortality rate of 0-7%.
With appropriate treatment, high-risk lesions have recurrent bleeding rates of 5 to 20 percent, depending upon the endoscopic appearance of the ulcer base. The majority of patients with UGI bleeding due to peptic ulcer disease will stop bleeding spontaneously, and most will not re-bleed during hospitalisation.
Also, remember to consider whether there are any modifiable predisposing risk factors for ulcer formation e.g. stopping NSAIDs / smoking / H. pylori) and treated as appropriate.
Intubating the unstable GI bleeder
Massive GI hemorrhage presents a number of challenges during and after intubation
- Vocal cords are likely to be obscured by blood / vomit
- Haemodynamic instability from haemorrhagic shock
- Aspiration risk high
- Exposure risk to Staff from contact with body fluids
Steps to Maximise success
1. Use your airway checklist, consider and PLAN for the worst and prep your team.
2. WEAR PPE for all staff involved - especially Goggles, Gloves and Mask!
3. Empty the Stomach (if tolerated insert an NG and put it on low wall suction – varices are not a contraindication)
4. Administer prokinetic, eg Metoclopramide 10mg IV ( “proper” prokinesis is 20 mg) or erythromycin 250mg IV
5. Intubate with patient HOB at 45deg – but if the patient vomits - > Trendelenberg to get the vomit out of the lungs
6. Have an assistant allocated to the role of suctioning on the left, and have a spare Yanker sucker setup in case the first gets blocked.
7. Preoxygenate well with good seal (if possible) but try to avoid NIV if vomiting
8. Apneic oxygenation (using continuous Nasal prong oxygenation) is a must in these patients
9. BVM gently and slowly to re-oxygenate , if needed, (6-10 breaths /min)\
10. Use video laryngoscopy if available but have a standard laryngoscope blade ready in case of blood / fluids obscuring the camera.
11. Must Paralyze to optimize your 1st pass success. Where Suxamethonium contraindicated, Paralyze with Rocuronium 1-1.2mg/kg to minimize time to onset of action. Paralysis does not reduce the lower oesophageal tone.
12. Consider using a hemodynamically stable sedative like Ketamine 1-2mg/kg
13. No role initially for antibiotics in “chemical pneumonitis” from aspiration – but may require antibiotics (Ceftriaxone) if variceal bleed. SIRS response may require further fluid resuscitation +/-vasopressors.
Recent evidence suggests that all variceal bleeds should get antibiotics.
Further References and Resources
- EMCrit on Intubating the GI Bleeding Patient
- EMCrit on A novel set up for suctioning during intubation
- Evidence for no harm caused by insertion of NG in patients with varices: Digest Dis 1973;18(12):1032, Gastrointest Endosc. 2004 Feb;59(2):172-8, and Anesth Analg 1988;67:283)
Further References and Resources
- American Society for Gastrointestinal Endoscopy - 2012 guidelines
- American Society for Gastrointestinal Endoscopy - the role of endoscopy in the management of variceal haemorrhage - 2014 guidelines
- European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline - Endoscopic treatment of variceal upper gastrointestinal bleeding: - 2020
- American College of Gastroenterology - 2021 guidelines
- NICE Guidelines - Management of UGI bleeding - 2016
- NICE flow chart - Acute upper gastrointestinal bleeding overview
- British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding 2020