GI bleed for nurses

1. Management of Upper
Gastrointestinal Bleeding in A&E
Basildon and Thurrock University Hospital NHS Trust
M Rasool Aljabiri

2. Perspective
• Integrated care pathway (ICP)
• Multidisciplinary
• To incorporate latest BSG & JAG guidelines
• Evidence Based
• Streamline management & admission avoidance
• Audit morbidity & mortality
 Approved
• Aim is to update our nurses on management o
UGIB
• Morbidity
• Mortality

3. Gastrointestinal Bleeding
• Objectives of the Presentation:
• A ‘nuts and bolts” review of GI bleeding:
presentation
approach to the patient,
aetiologies
• Role of endoscopy in triage of patients with UGI
bleeding

4. Gastrointestinal Bleeding
• Voltaire, 1786
– ……..”the art of medicine is to amuse the
patient while nature heals the disease”

5. Gastrointestinal Bleeding
• Introduction:
– GI bleeding is a common disorder that
troubles all medical/surgical specialties
– UGI bleeding>LGI bleeding
– Prevalence: 170 cases/100K adults/yr
– Cost estimate: £7B/yr (USA)
– 6%-8% mortality (10%) (unchanged since
1945)
– Severity: acute/chronic/intermittent/occult

6. MWS

7. Gastrointestinal Bleeding
• UGI bleeding (2225 patients):
– Diagnoses: %
• DU 24.3
• Gastric erosion, “itis” 23.4
• GU 21.3
• Varices 10.3
• M-W tear 7.2
• Esophagitis 6.3
• Duodenitis 5.8
• Neoplasm 2.9
• Esophageal ulcer 1.7
• Other 8.0

8. Gastrointestinal Bleeding
• Presentation of bleeding:
– Hematemesis-UGI source
– Melena-UGI source usually but 5% can be
from LGI source
– Hematochezia (BRBPR)-LGI source usually
but 15% from UGI source
– Occult-UGI or LGI source

9. Gastrointestinal Bleeding
• UGI vs LGI location
determined by the Ligament
of Treitz:
– UGI – proximal to LT
• *Oesophagus, *stomach,
*duodenal bulb, 2nd/3rd portion of
duodenum
– LGI – distal to LT
• Small bowel, *colon

10. Gastrointestinal Bleeding
• Determine the urgency of the clinical situation:
– Is the patient in shock?
• 40% loss of circulating blood volume
• Agitation, pallor, tachycardia, hypotension
– Is the patient orthostatic?
• 20% loss of circulating blood volume
• Postural hypotension
– Never rely on initial H/H values to asses amount of
blood loss (hemoconcentration)

11. YOU
Believe me am
a DOCTOR

12. Gastrointestinal Bleeding
• Initial management of GI bleeding:
– History/physical exam
– Replace intravascular volume
– Nasogastric intubation
– Supplemental nasal oxygen
– Laboratory evaluation:
CBC/platelets/INR/PTT/BUN/creatinine
– Asses need for admission to hospital

13. Endoscopic appearance at 17 cm
Tongue of tissue at posterior aspect
of oesophagus
Endoscopic appearance at 34 cm
Bx taken

14. Management of Upper GI Bleeding in
A&E
• Triage & Resuscitation
• Identifying likely variceal bleeds
• Stratifying high from low risk bleeds
– Rockall Score

15. Gastrointestinal Bleeding
• Prognostic factors in UGI bleeding:
• severity of initial bleed
• age of patient
• co-morbidities
• onset of bleeding in hospital
• giant ulcer seen at endoscopy
• endoscopic stgimata present at endoscopy
• need for emergency surgery

16. Gastrointestinal Bleeding
• Diagnostic/therapeutic modalities:
– Endoscopy – upper/lower
– Radionuclide scanning
– Angiography
– Capsule endoscopy (not in acute situation)
– NEVER EVER USE BARIUM IN ACUTE GI
BLEEDING

17. VON MIKULICZ SCOPE 1880

18. Gastrointestinal Bleeding
• UGI bleeding:
– Finding % rebleed % mortality
• Active bleeding 55 11
• Visible vessel 43 11
• Adherent clot 22 7
• Flat, pigment spot 10 3
• Clean based ulcer <5 2
– Lane, et al. 1994, NEJM, 31: 717-27

19. Gastrointestinal Bleeding
• Uncommon etiologies of UGI bleeding:
– GAVE (gastric antral vascular ectasia)
– Dieulafoy’s lesion (vessel without ulcer
base)
– Portal hypertensive gastropathy
– Aorto-enteric fistula
Hematobilia
– UGI GIST tumor

20. GAVE (gastric antral vascular ectasia)

21. Dieulafoy’s lesion (vessel without
ulcer base)

22. Portal hypertensive gastropathy

23. Aorto-enteric fistula

24. Hematobilia

25. UGI GIST tumor

26. Gastrointestinal Bleeding
• UGI bleeding in portal hypertension: Varices
– High mortality on first bleed, 70% rebleed rate in
next 12 months
– Start IV Terlipressin in all suspected PHT bleeds
– Endoscopic ligation is procedure of choice
(prophylactic banding is standard of care,
surveillance for variceal recanalization)
– TIPS for endoscopy failures
– Surgical (shunts, transection, splenectomy

27. Gastrointestinal Bleeding
• Special considerations in UGI bleeding:
– Evaluate and treat Helicobacter pylori infections in
the peptic disorder
– Keep Nsaid’s in mind in all patients (the cause of non-
healing until proven otherwise)
– Stress related mucosal disease (SRMD) in
hospitalized patients with non-bleeding illnesses
– Suppress gastric acid secretion
– Correct coagulopathy in most cases

28. Management
Non-variceal bleeding
Variceal bleeding (Sengstaken Blakemore tubes)
Endoscopy
Timing
Site
Staffing/support
(Post endoscopic care)

29. Resuscitation
• Airway
• Breathing
• Circulation
1. Insert 2 large bore cannulae
2. Correct fluid losses
3. Restore Blood Pressure
4. Send blood for FBC, clotting, U&E & LFTs.
5. Group & Save & Crossmatch
• 6 units for suspected variceal bleeding
• 4 units if haematemesis/melaena or if BP<100 mmHg systolic
• Otherwise group & save

30. Identifying possible variceal bleeds
Varices develop as a complication of portal venous
hypertension & portal venous collateral flow in liver disease
• Is there any history of
liver disease?
• Is there a history of
alcoholism or viral
hepatitis?
• Are there any
stigmata of chronic
liver disease on
examination?

31. Stigmata of chronic liver disease

32. If stigmata of chronic liver disease then
treat as high risk variceal bleed until
proven otherwise
Give 2mg terlipressin (glypressin) iv
as bolus
 If evidence of ischaemia on ECG or history of
peripheral vascular disease, then give octreotide
instead (50 mcg bolus followed by 50 mcg/hour
as infusion)

34. If initial Rockall Score is ≥ 3 or
assumed variceal bleed: High Risk
1. Immediately inform medical SpR on call who should
discuss with gastro SpR on call via switchboard. If the
bleed is suspected to be from an ulcer, then the
surgical SpR should also be informed.
2. Give colloid whilst waiting for blood, if shocked.
3. Insert urinary catheter and consider inserting CVP line.
4. Give 1 pool of platelets if platelet count < 50,000 and 2
units of FFP if INR >1.5.
5. Endoscopy should only be considered once the patient
has been suitably resuscitated & only if this can be
done in a safe and supported environment.

35. If initial Rockall Score is 1 or 2:
Low Risk
1. Admit to general medical ward.
2. Regular observations & stool chart.
3. Start oral omeprazole 20mg or
lansoprazole 30mg once daily.
4. Plan for endoscopy to be done on the next
available ‘in hours’ list.

36. If initial Rockall Score is 0 (and Hb
>10 g/dl) : Very low risk
• Discuss with on-call gastro SpR via
switchboard - consider early discharge with
outpatient endoscopy where indicated.
• Start oral omeprazole 20mg or lansoprazole
30mg once daily.

37. Endoscopy: Site
• If the patient has a suspected variceal bleed or
is unstable the endoscopy should be performed
in ICU or theatres (many of the nurses in
theatres are trained to assist with endoscopic
procedures) with anaesthetic support.
• The consultant gastroenterologist on call should
be made aware and a suitably trained nurse
should be present to assist with any endoscopic
interventions.

38. Endoscopy: timing
The patient should be as optimally
resuscitated as possible and the endoscopy
arranged within 4 hours if Rockall Score ≥3.
In the case of a suspected variceal bleed
endoscopy should be done ASAP.

39. Endoscopy: support
The airway should be protected by elective
intubation if there is:
• Severe uncontrolled bleeding
• Severe encephalopathy
• Inability to maintain O2 saturation >90%
• Aspiration pneumonia

40. Uncontrolled variceal bleeding
• If the bleeding is
uncontrolled (either pre- or
post endoscopy) and
presumed to be variceal in
origin then a Sengstaken
Blakemore tube should be
inserted.

42. Ideally the patient
should be
intubated to
protect the airway
prior to insertion

43. Pre/Post Endoscopic Variceal
Bleeding Management
1. Patients should be transfused up to a Hb
of 7-8 g/dl. Transfusion to Hb >8 can
cause further re-bleeding.
2. Give terlipressin 2mg iv every 4 hours.
3. Give empirical iv broad spectrum
antibiotics at time of admission eg: iv
cefotaxime 2g or ciprofloxacin 400mg iv.
4. Avoid insertion of NG tube within 48
hours of variceal band ligation.

45. Treatment options
• Inject
• Thermal (heat, APC)
• GOLD PROBE with high flow flush
• Mechanical therapy
– Hemo Clip
• Band + BB
• GLUE
• NEW SPRAY --- wait for it-- INCREDIBLE
• DO NOT FORGET PPI,BB AND
TERLIPRESIN.
• IF Rebleeds

48. Gastrointestinal Bleeding
• LGI bleeding:
– Older patient
– Presentation
• Hematochezia
• BRBPR
• Maroon stool
• Occult+ stool
• Iron deficiency anemia (GI blood loss until proven
otherwise)

49. Gastrointestinal Bleeding
• Major LGI bleeding:
– Diagnosis %Diagnoses
• Diverticulosis 43
• Angiodysplasia (avm’s) 30
• Neoplasia 9
• Colitis 9
• Other 7
• Undetermined 12

50. Gastrointestinal Bleeding
• Diverticulosis:
– Occurs in 3% of pts with diverticulosis
– Acute, painless bleeding presenting with
bright red blood/maroon stool
– Right colon usual site 20% episodes are
recurrent/persistent
– Colonoscopy after bowel prep
– Tagged RBC scans/angiography

53. Gastrointestinal Bleeding
• Angiodysplasia (avm’s)
– Presentation: acute major hemorrhage/slow
intermittent bleeding/FOBT+ stool/iron
deficiency anemia
– Pts with major hemorrhage usually hane a
coagulopathy
– Colonoscopy/small bowel capsule endoscopy

55. Gastrointestinal Bleeding
• Neoplasms:
– Benign/malignant
– Major hemorrhage is rare (iron deficiency
anemia, +/- FOBT)
– Colonoscopy/capsule endoscopy/angiography

58. Gastrointestinal Bleeding
• Anorectal/Perianal disease:
– Common cause of BRBPR
• *hemorrhoids
– Minor, intermittent bleeding with defecation
– Always a diagnosis of exclusion after more
serious lesions in the GI tract have been ruled
out (CRC/polyps/colitis)

60. Gastrointestinal Bleeding
• Role of endoscopy in triage of UGI
bleeders:
• Accurate identification of the urgency of the clinical
situation: hemodynamic compromise/signs of on-
going bleeding/coagulopathy/co-morbidities
• Who should be hospitalized?
• Where to admit?
• Diagnosing the cause
• Risk stratification