This is about the management approach to a patient presenting with acute upper gastrointestinal bleeding. A brief account on epidemiology and pathophysiology is included. This is mainly based on NICE guideline & journal of hepatology.

1. ACUTE UPPER
GASTROINTESTINAL
BLEEDING
Dr KTD Priyadarshani
Registrar – Emergency Medicine
2022/11/11

2. SCOPE
■ Introduction and epidemiology
■ Pathophysiology
■ Initial assessment
■ Management-Resuscitation
■ Definitive management
– Variceal bleeding
– Non variceal bleeding

3. INTRODUCTION
■ Upper GI bleeding is any
GI bleeding originating
proximal to the
ligament of Treitz.
■ Approximately 50-
70,000 admissions per
year [NICE-2016].

4. EPIDEMIOLOGY
■ The overall incidence of acute upper GI bleeding in
the UK ranges from 84-172 per 100,000 of the
population/ year
■ Incidence is highest in the elderly, and lower
socioeconomic groups.
■ Despite changes in medical management, mortality
has remained at around 10% for the last fifty years
[NICE- 2016]

5. PATHOPHYSIOLOGY
■ Peptic ulcer disease
■ Mallory-weiss syndrome
■ Erosive gastritis and esophagitis
■ Esophageal and gastric varices
■ Other causes-arteriovenous malformation and
malignancy

6. BJA-UGIB

7. INITIAL ASSESSMENT

8. HISTORY
■ Clinical presentation
• Hematemesis
• Coffee-ground emesis
• Melena
• Hematochezia (14% cases from UGIB)
• Anemia
• Hypovolemic shock
• Vomiting and retching, followed by hematemesis,
suggest a Mallory- Weiss tear.

9. • History of GI bleeds (rebleed at same site is
common)
• Peptic ulcer disease symptoms
• Esophageal or Gastric Variceal Bleed
• Heavy alcohol use (consider diagnosis of
esophageal/gastric variceal bleeding)
• Cirrhosis and known varices
• Extreme valsalva maneuvers: consider Mallory-
Weiss Syndrome

10. • Aortic or GI tract surgeries: consider aortoenteric
fistulas vs. post-surgical anastomotic ulcers
• GI neoplasms
• Drug Hx- Salicylates, glucocorticoids, NSAIDs, and
anticoagulants all place the patient at high risk for
GI bleed.
• Alcohol abuse is strongly associated with a number
of causes of bleeding, including peptic ulcer
disease, erosive gastritis, and esophageal varices.
• Liquid medications with red dye, as well as certain
foods, such as beets, can simulate hematochezia.
In such cases, stool guaiac testing will be negative

11. PHYSICAL EXAMINATION
• Visual inspection of the vomitus for a bloody, maroon, or
coffee ground appearance is the most reliable way to
diagnose upper GI bleeding in the ED
• Review vital signs looking for hemodynamic compromise
(tachycardia, hypotension, tachypnea)
• Look for evidence of shock: confusion, peripheral
vasoconstriction
• Evidence of liver disease
• Jaundice, ascites, spider angiomas, caput medusae
• Increases risk of variceal bleeding

12. ■ Petechiae and purpura suggest an underlying
coagulopathy.
■ A careful ear, nose, and throat examination can
reveal an occult bleeding source that has resulted
in swallowed blood and subsequent coffee-ground
emesis
■ Abdominal examination may disclose tenderness,
masses, ascites, or organomegaly.
■ Perform rectal examination to detect the presence
of blood and its appearance, whether bright red,
maroon, or melana

13. RISK ASSESSMENT
1. The Glasgow- Blatchford score at first assessment
2. AIMS 65 score
3. The full Rockall score after endoscopy

14. GLASGOW- BLATCHFORD
SCORE
■ A screening tool to assess the likelihood that a
person with an acute upper gastrointestinal
bleeding (UGIB) will need to have medical
intervention such as a blood transfusion or
endoscopic intervention
■ The tool may be able to identify people who do not
need to be admitted to hospital after a UGIB

15. Scores of 6 or more were associated with a greater than 50% risk of needing an intervention

16. AIMS65 SCORE
■ Better predict mortality than the Glasgow-
Blatchford score
■ But less sensitive than Glasgow Blatchford score for
needing intervention

17. ROCKALL SCORE
■ This was principally designed to predict death based on a
combination of both clinical and endoscopic findings.
■ The score consists of three clinical parameters (age,
presence of shock, and comorbidity) and two parameters
that rely on endoscopic findings (blood and diagnosis).
■ The maximum pre-endoscopy Rockall score is 7 and post-
endoscopy is 11.
■ A Rockall score of 3 before endoscopy approximates with
a 10% mortality rate and a score of 6, a 50% mortality
rate

18. Score <3 Excellent prognosis
Score >8 High mortality

19. RISK ASSESSMENT SUMMARY
■ Risk is categorized the following way:
• Low risk: Blatchford Score 0 – consider discharge
with outpatient endoscopy
• Moderate risk: admit to appropriate inpatient
specialty for urgent endoscopy
• High risk: Rockall Score (pre-endoscopy) 3,
hemodynamic instability, known varices –
resuscitate, admit to critical care area for emergency
endoscopy

20. MANAGEMENT

22. INVESTIGATIONS
■ Blood investigations
– FBC
– Coagulation profile
– LFT
– Lactate levels
■ CXR
■ CT Angiography
– If endoscopy is unsuccessful at locating bleeding source
– Reported to have 100% specificity for UGIB but is dependent on
the bleeding rate
{Mihata RGK,Bonk JA,Keville MP et al 2013}

23. MANAGEMENT OF VARICEAL
BLEEDING

24. RESUSCITATION
• A- Intubate if risk of aspiration Or if low GCS
• B- High flow O2 to maintain SpO2
• C- Large bore IV access
– Crystalloids to restore circulating volume
– MAP target >65mmHg
– Restrictive blood transfusion strategy is recommended as More
liberal transfusion strategies increase rebleeding and mortality
rates, probably in part by increasing the portal pressure
– activate massive transfusion protocol if indicated
– Hb target- >7g/dL (8-10 g/dL in coronary artery disease)
■ D- GCS

25. ■ Correct underlying bleeding diathesis
– Platelet- if bleeding presence of a platelet
<50*109/L
– Coalulation derangement- FFP, Cryoprecipitate
– Warfarin or rivaroxaban- prothrombin complex
concentrate
– Stop aspirin, NSAIDs and anticoagulants
– Tranexamic acid is currently not recommended
{HALT-IT trial 1927-1936}

26. ■ Terlipressin and intravenous antibiotics controls bleeding in
80% of patients with variceal haemorrhage
– Terlipressin ( vasopressin analogue- splanchnic vasoconstriction)
■ SE- vasoconstriction- MI & peripheral ischemia
■ Stop treatment after definitive hemostasis has been achieved,
or after 5 days.
– Octreotide (somatostatin analogue)
■ Antibiotic therapy
– Offer prophylactic antibiotic therapy at presentation to patients
with suspected or confirmed variceal bleeding
– Ciprofloxacin or ceftriaxone

27. ■ Balloon tamponade- consider as a temporary salvage procedure in
uncontrolled variceal hemorrhage.
– Sengstaken- Blakemore tube
– Minnesota tube

28. ■ General guidelines for use of a balloon tamponade {Mihita RGK,
Bonk JA, Keville MP et al 2013}
– Secure the airway
– Apply lubricant to the tube and insert through the mouth or nostril to a
depth of at least 50 cm
– Evaluate by injecting approximately 50 ml of air into the gastric
balloon and obtain an Xray to confirm placement in the stomach
– Inflate the gastric balloon
– Retract the tube until resistance is felt, and apply tension
– If the gastric balloon does not tamponade bleeding, inflate the
esophageal balloon (25-30 mmHg)

29. ENDOSCOPY
■ Timing- depend on pre endoscopy Rockall score & local facilities
– Offer endoscopy to unstable patients with severe acute upper
gastrointestinal bleeding immediately after resuscitation.
– Offer endoscopy within 24 hours of admission to all other
patients with upper gastrointestinal bleeding
■ Techniques
– Variceal band ligation is the preferred treatment for
oesophageal varices.
– Endoscopic injection of N -butyl-2-cyanoacrylate (‘glue’) may be
appropriate for the treatment of gastric varices
NICE 2016

30. ■ If haemostasis cannot be achieved by endoscopy
– balloon tamponade with a Sengstaken-Blackmore
tube
– Trans jugular intrahepatic portosystemic shunt
should be considered if hemostasis cannot be
achieved endoscopically or the patient rebleeds
■ Combination of non-selective beta-blocker in addition to
variceal band ligation for secondary prophylaxis of
variceal bleeds
– Carvidilol 6.25-12.5 mg daily

32. MANAGEMENT OF NON-
VARICEAL BLEEDING

33. MANAGEMENT OF NON-VARICEAL
BLEEDING
■ Endoscopic treatment-
– Do not use adrenaline as monotherapy for the endoscopic
treatment of nonvariceal upper gastrointestinal bleeding
– For the endoscopic treatment of non-variceal upper
gastrointestinal bleeding, use one of the following:
■ a mechanical method (for example, clips) with or without
adrenaline
■ thermal coagulation with adrenaline
■ fibrin or thrombin with adrenaline
NICE- 2016

34. Proton pump inhibitors
■ Esomeprazole or Pantaprazole 80mg IV bolus over 30 min
followed by 8mg/h (2019)
■ Do not offer acid-suppression drugs (proton pump inhibitors or
H2-receptor antagonists) before endoscopy to patients with
suspected non-variceal upper gastrointestinal bleeding-(NICE
2016)
– An updated large Cochrane meta-analysis showed that
compared with H2 blocker or placebo, PPI reduced re-
bleeding, surgical intervention and need for repeated
endoscopic treatment in known PUD.
– However, it has not been shown to reduce mortality,
rebleeding and surgical intervention in the
undifferentiated UGIB {Sreedharan A, Martin J, Leontiadis GI et al, 2010}

35. ■ Current international consensus guidelines
recommend high-dose IV PPI therapy e.g.
Pantoprazole 80 mg bolus followed by 8 mg h1 for
3 days
■ Helicobacter pylori eradication should be offered to
all who test positive for the infection. Eradication
therapy was shown to be superior to PPI alone in
preventing re-bleeding

36. Rebleeds after endoscopy..
■ Consider repeat endoscopy, with treatment as
appropriate, for all patients at high risk of re-bleeding,
particularly if there is doubt about adequate hemostasis
at the first endoscopy.
■ NICE suggest offering a repeat endoscopy in the event of
rebleeding with a view to further endoscopic treatment or
emergency surgery.
■ However, unstable patients who re-bleed require
interventional radiology. If there is a delay in such
therapy, urgent referral for surgery should be made

38. REFERENCES
■ NICE guideline-UGIB
■ Journal of hepatology-2018
■ Life in the fast lane
■ RCEM

39. QUESTIONS?