Management of upper gastrointestinal bleeding

Upper gastrointestinal (UGI) bleeding is a life threatening condition that you need quickly recognise and manage appropriately in an acute setting. This guide gives an overview of the recognition and immediate management of upper gastrointestinal bleeding (using an ABCDE approach). 

Airway

Is the patient able to talk? – if so the airway can be considered patent

Noisy breathing suggests airway compromise

1. Perform head tilt, chin lift

2. If noisy breathing persists try a jaw thrust

3. If airway still appears compromised use an airway adjunct

• Insert an oropharyngeal airway (Guedel) only if unconscious (as otherwise may gag / aspirate) 
• Alternatively use a nasopharyngeal airway (better tolerated if patient is partially conscious)

Breathing

Administer oxygen

Give high flow oxygen via a non-rebreather mask if the patient is hypoxic.

Ensuring the patient is well oxygenated is important, but be ready to quickly remove the mask during episodes of haematemesis as this can result in aspiration.

Assess the patient

Oxygen saturation – aim for 94-98%

Respiratory rate:

• Tachypnoea is concerning and suggestive of respiratory compromise.
• A falling or normal respiratory rate in the context of hypoxia is a sign of impending respiratory failure and need for urgent critical care review.

Auscultate both lungs to assess air entry – reduced or absent air entry may suggest aspiration / consolidation / pleural effusion / lobar collapse / pneumothorax

Circulation

IV access

Insert two large bore cannulae (14-16G).

This is essential in the context of upper gastrointestinal bleeding as patients can quickly become haemodynamically unstable and require large volumes of fluid and/or blood transfusion.

 

Bloods

Take bloods off after inserting the cannula:

• FBC – Hb may be decreased – but often appears normal in the context of acute blood loss
• Clotting – deranged in liver disease and may indicate the need to replace clotting factors
• Group & Crossmatch – requesting blood early is essential – in emergency use O neg blood
• U&Es – ↑ urea occurs in UGI bleeds due to digestion and absorption of blood proteins
• LFTs – if liver disease is suspected then this can assist in confirming the diagnosis

Observations

• Blood pressure – haemodynamic instability suggests significant blood loss 
• Heart rate – tachycardia can be an early sign of volume depletion
• Capillary refill time – central CRT gives a rough estimate of volume status – should be <2 secs

Fluid resuscitation and blood transfusion

Fluid

• Patients’ are often haemodynamically unstable.
• Fluid is useful for replacing volume loss – to maintain adequate BP for end organ perfusion
• Crystalloid vs Colloid  – studies have not demonstrated any difference in outcome
• The rate of fluid replacement depends on the rate of loss – BP and urine output can help guide this
• If the patient is losing significant volumes of blood, fluid replacement alone is inadequate and blood transfusion needs to be arranged.

 

Blood transfusion

• Hb can be misleading in acute bleeds as it only decreases once haemodilution has occurred.
• NICE suggests Hb of <10g/dL as the cut off for transfusing blood to avoid underestimation.
• Give compatible blood when available – rate of transfusion guided by haemoglobin level and estimated blood loss
• If patient is losing blood rapidly – don’t wait for crossmatching – give O negative blood instead (this would be a senior led decision)

 

Platelets and clotting factors

Patients’ may have deranged platelets and clotting factors which are contributing to the bleed.  This is often due to pre-existing liver disease and splenomegaly.

NICE guidance in regard to the use of platelets and clotting factors is as follows:²

 

Platelets

If a patient is not actively bleeding and is haemodynamically stable, platelets should not be administered.

Only offer platelets to patients actively bleeding with a platelet count <50 x10⁹/L.

 

Fresh frozen plasma (FFP)

Offer fresh frozen plasma to patients who have either:

• Fibrinogen <1g/litre
• Prothrombin > 1.5 times the normal level

This should be a consultant led decision with haematology input.

 

Prothrombin complex

Give prothrombin complex concentrate to those taking warfarin and actively bleeding.

This should be a consultant led decision with haematology input.

 

Recombinant factor VIIa

Only offer recombinant factor VIIa when all other methods have failed.

This should be a consultant led decision with haematology input.

Monitor urine output

It’s useful to monitor urine output in haemodynamically unstable patients.

This is because urine output provides a proxy measurement of end organ perfusion.

If the kidneys are not getting sufficient perfusion, urine output falls.

Aim for a urine output of >30mls/hr.

 

Terlipressin

Terlipressin causes vasodilation of the splenic artery, reducing blood pressure in the portal system.  It is recommended for use in all patients with suspected variceal bleeding at presentation². It should be stopped once definitive haemostasis has been achieved.

Again this should be a consultant led decision.

Endoscopy

Endoscopy should be performed on all unstable patients with severe UGI bleeding immediately after resuscitation². It should be performed within 24 hours of admission for all other patients with upper GI bleeding.  This allows the diagnostic confirmation and the opportunity to treat any bleeding sites.

It’s essential to get input from an experienced gastroenterologist and anaesthetist early.

 

The type of endoscopic treatment varies depending upon the cause of the bleeding

 

Variceal bleeding

• Band ligation
• Injection sclerotherapy
• Balloon tamponade

Prophylactic antibiotic therapy is recommended for patients with suspected or confirmed variceal bleeding².

 

Non-variceal bleed (e.g. ulcer)

• Endoclips +/- adrenaline
• Thermal coagulation with adrenaline
• Fibrin or thrombin with adrenaline

Patients should be kept nil by mouth before the endoscopy and for at least 8-12 hours afterwards.  If the patient is continuing to bleed then emergency endoscopic intervention is required.

 

Commence an IV PPI – after endoscopic diagnosis

Proton pump inhibitors (PPIs) reduce the amount of acid produced by the stomach.  This is useful because high concentrations of acid increase the probability of re-bleeding due to decreased clot stability.  

There is no evidence that giving a PPI prior to endoscopic diagnosis of UGI bleeding is beneficial and therefore NICE recommends NOT administering PPI medication prior to endoscopic diagnosis.

PPIs are recommended post endoscopic diagnosis of UGI bleeding and are usually administered as an infusion for at least 72 hours to reduce the chance of re-bleeding².

Disability

AVPU / GCS – ↓ consciousness may suggest cerebral hypo-perfusion or hepatic encephalopathy.

Check capillary blood glucose – often deranged in liver disease

Exposure

Adequate exposure is essential to ensure you don’t miss diagnostic clues:

• Rectal examination – Melaena-  supporting a diagnosis of UGI bleeding
• Stigmata of chronic liver disease – spider naevi, caput medusae, ascites
• Bruising  – may indicate coagulopathy
• Evidence of trauma / blood loss from other sites

Reassess ABCDE

It is essential to continually reassess ABCDE and treat issues as you encounter them.  This allows continual reassessment of the response to treatment and early recognition of deterioration.

If the patient does not respond to treatment, or deteriorates,  critical care input should be involved as soon as possible.

Risk scoring systems

Blatchford score

The Blatchford score is calculated prior to endoscopy and is based on simple clinical and laboratory parameters. Its principle use is to identify low risk patients’ who do not require any intervention (blood transfusion, endoscopic therapy, surgery). Approximately 20% of patients’ presenting with upper GI haemorrhage have a Blatchford score of zero. Such patients’ can largely be managed safely in the community, as the mortality in this group is nil.³

Rockall score

It is important to identify those patients who are at risk of ongoing bleeding and death.
The Rockall scoring system is used for risk categorisation based on simple clinical parameters. Rockall scores can be calculated both before and after endoscopy, but the post endoscopy rockall score provides a more accurate risk assessment. It provides independent risk factors which have been shown to
accurately predict the risk of rebleeding and mortality.³

 

With increasing age there is an increased risk of death:³

• Mortality in those aged below 40 is negligible.
• Mortality increases to 30% in those aged over 90.
• Patients’ who have evidence of active bleeding and signs of shock have an 80% risk of death.
• Those with a non-bleeding visible vessel at endoscopy have a 50% chance of re-bleeding.

References

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