This document summarizes the management of upper gastrointestinal hemorrhage. It discusses risk stratification tools like the Rockall score to determine a patient's risk level. For low risk patients, outpatient care may be appropriate. It also reviews the causes, evaluation, and endoscopic and pharmacologic treatment approaches for acute non-variceal and variceal bleeding.

1. Upper GI Hemorrhage: Emergency Management พญ . ปิยะธิดา หาญสมบูรณ์ หัวหน้างานโรคทางเดินอาหาร กลุ่มงานอายุรศาสตร์ โรงพยาบาลราชวิถี

2. Admission Rate 100/100,000 Incidence 50-100/100,000 per year

3. Clinical Manifestations: Hematemesis Melena Hematochezia

4. Causes of acute upper gastrointestinal harmorrhage 5 Rare 5 Vascular malformations 1 Upper gastrointestinal malignancy 15 Mallory Weiss tear 5-10 Varices 5-15 Oesophagitis 8-15 Gastroduodenal erosions 35-50 Peptic ulcer Approx% Diagnosis

5. Acute Nonvariceal hemorrhage

6. Acute Variceal hemorrhage

7. Portal Hypertensive Gastropathy

8. Basic Principle in Management Rapid Assessment Initial Resuscitation

9. When? How many ?

10. When to transfuse blood? Changes in vital signs Continuous bleeding Signs of poor tissue oxygenation Low hematocrit (Hct 20-25%)

11. Target Hemoglobin 10mg/dL Elder Hemoglobin 7-8 mg/dL normal adult Hemoglobin 9 mg/dL patient with portal hypertension Fresh Frozen Plasma 1 unit/ 4 units PRC Platelet concentration if < 50,000

12. Assessment

13. Important History history of oropharyngeal disease anemia weight loss change in bowel habit abdominal pain use of anticoagulation and/or antiplatelet therapy use of nonsteroidal anti-inflammatory drugs including aspirin underlying medical disorder (especially liver disease) previous gastrointestinal surgery previous gastrointestinal disease prior gastrointestinal bleeding age

14. Hemodynamic status and severity of GI bleeding minor <10 Normal Moderate 10-20 Postural (orthostatic hypotension and tachycardia) Massive 20-25 Shock (resting hypotension) Severity of bleed Blood loss (% of intravascular vol) Vital Signs

15. Characteristics of vomitus Bright red vomitus Coffee ground

16. Objectives of NG Lavage Appearance of gastric content Clear the stomach for the endoscopy Prevent pulmonary aspiration

17. Cappelli MS, et al. High risk gastrointestinal bleeding. Gastroenterol Clin N Am . 2000;29(2) Aljabreen AM, Fallone CA, Barkun AN. Nasogastric aspirate predicts high risk endoscopic lesions in patients with acute upper GI bleeding. Gastrointest Endosc . 2004;59:172. 28.7 Red 19.4 Brown 12.3 Black Red Blood 19.1 Red 8.2 Brown or black Coffee ground 6 Brown or Red Clear Mortality % Stool color NG aspirate color

18. Risk Stratification

19. The Rockall risk score scheme Rockall Score > 2 High Risk Maximum additive score prior to diagnosis=7, maximum additive score following diagnosis=11. BP, blood pressure; SRH, stigmata of recent hemorrhage － Blood in upper gastrointestinal tract, adherent clot, visible or spurting vessel － None or dark spot only Major stigmata of recent hemorrhage － Malignancy of upper gastrointestinal tract All other diagnoses Mallory-Weiss tear, no lesion identified and no SRH Diagnosis Renal failure, liver failure, disseminated malignancy Cardiac failure, ischemic heart disease, any major comorbidity － No major comorbidity Comorbidity － Hypotension (systolic BP<100) Tachycardia (systolic BP  100, pulse>100) No shock (systolic BP  100, pulse<100) Shock － >80 60-79 <60 Age (years) 3 2 1 0 Score Value

20. Rockall score < 2 could be safely managed in OPD setting Rockall T, Logan R, Devlin H, et al. Selection of patients for early discharged or outpatient care after acute gastrointestinal hemorrhage. Lancet . 1996;347:1138-40.

21. Cipoletta criteria Endoscopic absence of varices, other signs of portal hypertension, or high risk stigmata of recent hemorrhage Absence of hypovolemic shock or orthostasis Hb > 8mg/dL and no blood transfusion Normal coagulation studies Absence of serious medical illness Easy accessibility to hospital and adequate social/family support Capoletta L, BiancoM, Rotondana G, et al. Outpatient management for low risk nonvariceal upper GI bleeding; a randomized controlled trial. Gastrointest Endosc .2002;55:1-5

22. Longstreth Guidelines for selecting Patient with acute UGIH for OPD care Absolute No high risk endoscopic features, varices,or portal hypertensive gastropathy Not absolute No debilitation No orthostatic vital sigh changes No severe liver disease No anticoagulation therapy or coagulopathy No fresh, voluminous hematemesis or multiple episodes of melena on the day of presentation No severe anemia (hemoglobin 8 g/dL) Adequate support at home Longstreth G, Feitelberg S. Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series. Gastrointest Endosc . 1998;47:219-222.

23. University of California,San Francisco (UCSF) Triage Very Low Risk age < 60 Absence of major cormorbid No Hx of red hematemesis, hematochezia or bright red nasogastric aspirate No Hemodynamic instability No significant coagulopathy and profound anemia D/C from ER Outpatient workup Elmunzer BJ, Inadomi JM, Elta GH. Risk Stratification in Upper Gastrointestinal Bleeding. J Clin Gastroenterol 2007;41:559-563.

24. LOW Risk Hemodynamic stable within 1 hour of resuscitation No recent red hematemesis, hematochezia, or bright red nasogastric aspirate No active cardiopulmonary or liver disease No significant coagulopathy or profound anemia Allow: Age> 60,coffee ground in NG aspirate, presence of compensated comorbidities,and initial hemodynamic compromise EGD Low risk D/C from ER Outpatient workup Elmunzer BJ, Inadomi JM, Elta GH. Risk Stratification in Upper Gastrointestinal Bleeding. J Clin Gastroenterol 2007;41:559-563 .

25. Blantchford Score Blantchford score > 0 High Risk 6 < 10 1 10 - 12 g / dL Hemoglobin level for women ( g / dL ) 6 < 10 3 10 - 11 g / dL 1 12 - 13 g / dL Hemoglobin level for men ( g / dL ) 6 > 70 4 > 28 - 70 3 > 22.4 - 28 2 > 18.2 – 22.4 Blood urea nitrogen level ( mg / dL ) Score Admission risk marker 2 Cardiac failure 2 Hepatic disease 2 Presentation with syncope 1 Presentation with melena 1 Pulse > 100 per min Other markers 3 <90 2 90 - 99 1 100 -109 Systolic blood pressures ( mm Hg ) Score Admission risk marker

26. The Rockall risk score scheme Clinical Rockall Score Maximum additive score prior to diagnosis=7, maximum additive score following diagnosis=11. BP, blood pressure; SRH, stigmata of recent hemorrhage － Blood in upper gastrointestinal tract, adherent clot, visible or spurting vessel － None or dark spot only Major stigmata of recent hemorrhage － Malignancy of upper gastrointestinal tract All other diagnoses Mallory-Weiss tear, no lesion identified and no SRH Diagnosis Renal failure, liver failure, disseminated malignancy Cardiac failure, ischemic heart disease, any major comorbidity － No major comorbidity Comorbidity － Hypotension (systolic BP<100) Tachycardia (systolic BP  100, pulse>100) No shock (systolic BP  100, pulse<100) Shock － >80 60-79 <60 Age (years) 3 2 1 0 Score Value

27. Clinical Rockall score 0, no adverse outcomes 1-3,no adverse outcomes, 29% need transfusion >3 ,21% rebleeding, 5%surgery, 10% death OPD workup Tham TCK, James C, Kelly M. Predicting outcome of acute non variceal upper gastrointestinal hemorrhage without endoscopy using clinical Rockall score. Postgrad Med J 2006;82:757-759. Clinical Rockall < 3

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29. High Risk factors Host factors: Age > 60 yrs Cormorbid conditions Hemostatic instability,orthostatic hypotension, PR> 100,BP < 100 Coagulopathy Bleeding character: Continuous red blood from NG Red blood per rectum Patient course: Need blood transfusion Hemodynamic instability

30. Acute Non Variceal Hemorrhage

31. Bleeding Peptic Ulcer － Epidemiology － More than 300,000 hospital admissions annually in the US 1 Incidence: 103 cases/100,000 adults/year 2 Mortality: 5~14% 3 , unchanged for the past two decades, exclusively among elderly patients with significant comorbidities 1 Yavorski RT et al. Am J Gastroenterol 1995; 90:568-73 2 Longstreth GF. Am J Gastroenterol 1995; 90:206-10 3 Rockall TA et al. BMJ 1995; 38:222-6

32. Bleeding Peptic Ulcer － Natural History － Approximately 80-85% bleeding stops spontaneously Remaining 15-20% recurrent or continuous bleeding Early risk- stratification facilitates appropriate level of care Multidisciplinary approach

33. Laine et al. NEJM 1994; 331:717 Risk of rebleeding correlated with endoscopic bleeding stigma 11 43 11 7 3 2 Mortality 55 22 10 5 Rebleeding Active Bleed NBVV Adherent Clot Flat spot Clean- Base

34. Role of PPI

35. Keep gastric pH>6 Platelet aggregation and clot formation Principle

36. Omeprazole before endoscopy in patients with gastrointestinal bleedings Lau JY, Leung WK, Wu JC, et al. New Engl J Med . 2007 Apr 19;356(16): 1631-40. N 638 319 319 Omeprazole 80mgIV bolus, 8mg/hr placebo 19.1% 28.4% Endoscopic Rx

37. Reduced the need for endoscopic therapy Infusion of high dose Omeprazole before endoscopy acclerated the resolution of signs of bleeding in ulcers Lau JY, Leung WK, Wu JC, et al. New Engl J Med . 2007 Apr 19;356(16): 1631-40 .

38. High dose PPI after endoscopic therapy Decreased Rebleeding Decreased Surgery Cochrane systematic review 2005 Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000;343: 310-16 .

39. Endoscopic Management of Non variceal Hemorrhage Injection Therapy Thermal Devices Mechanical Devices

40. Acute Variceal Bleeding

41. Esophageal Varices 50% in cirrhosis 20% varices – large at presentation Developing rate 10-15% per year 1/3 varices bleed Mortality rate ~20-30% /bleeding episode 50% stop spontaneously

42. 72 >16 50 >15-16 17 >14-15 9 >13-14 0 < 13 Incidence of bleeding % Variceal Pressure mm Hg

44. Predicting Variceal Hemorrhage 72 60 44 52 40 28 34 23 16 +++ 54 38 28 33 23 15 19 12 8 + 42 30 20 26 16 10 15 10 6 - F3 F2 F1 F3 F2 F1 F3 F2 F1 C B A Red Wale Child Class

45. Risk Factors for recurrent hemorrhage Platelet clot on varice Red signs Red signs Active Bleeding on scope Active alcoholism Ascites Hepatoma Renal failure Ascites Severity of initial bleed Severity of liver failure Age > 60 Late Rebleeding >6wk Early Rebleeding <6wk

46. Sherry red spot (red color sign) Red Spot Red Wale sign (varices on varix)

47. Esophageal Varices Platelet clot

48. Initial Management: Resuscitation and Blood Transfusion (Keep hemoglobin 8gm/dl) Class I Level B Antibiotic prophylaxis for 7 days Norfloxacin 400 mg bid or IV Ciprofloxacin Class I Level A Ceftriazone 1 gm/day Class I Level B Pharmacologic Therapy 3-5 days Class I Level A Somatostatin and analogs Terlipressin EGD within 12 hours + EVL or sclerotherapy Class I Level A Balloon tamponade used as temporary measure (max 24 hours) Class I Level B ACG Practice Guideline 2007

49. N-2 butyl-cyanoacrylate for bleeding gastric varices: A United states pilot study and cost analysis Greenwald BD, Caldwell SH, Hespenheide EE, et al Am J Gastroenterol 2003 Sep;98(9):1982-8. Odd of Death > 7 fold non cyanoacrylate group 5/28 (18%) 1 year 1/30 (3%) 6 week 2/37 (5.5%) 72 hour Rebleeding 24/31 (29%) 1 year 30/34 (88%) 3 months survival

50. Role of Surgery Severe hemorrhage unresponsive to initial resuscitation Unavailable or failure of endoscopic therapy Coexisting 2 nd indication to operations such as perforation, obstruction or suspicious of malignancy

51. Thank you for your Attention