Author: Janet Skinner / Editor: Alasdair J Gray / Codes: CAP16, HAP16 / Published: 20/10/2009 / Review Date: 20/10/2012
Patients who suffer from an acute upper gastrointestinal (GI) haemorrhage are a common reason for presentation to emergency departments (ED) in the United Kingdom. They account for approximately 25,000 admissions per year. The incidence of upper GI haemorrhage is reported as ranging from 50 to 150 cases per 100,000 per year and are highest in areas of social deprivation. Mortality rates are high (10-14%), particularly in the elderly, and have not changed in last 50 years. However, patient populations are now older with greater comorbidity.
Upper GI haemorrhage can be defined as any bleeding which occurs from a source proximal to the Ligament of Trietz. The Ligament of Trietz is the suspensory ligament of the duodenum that marks the duodeno-jejunal junction. In peptic ulcer disease, haemorrhage occurs from erosion to an artery at the ulcer base. In patients with liver disease, increased portal venous pressure results ingreater blood flow through collateral vessels.
Identify fact that patient is having an upper GI bleed
- Easy features Haematemesis (present in 50%) and melaena (present in 70%)
- Not so easy syncope, dizziness, fresh PR bleeding, hypotension, tachycardia
Patients with haematemesis tend to have more severe bleeds than those with only melaena.
Points to look for in the history
- Known or suspected liver disease
- Profuse recent vomiting (suggests Mallory Weiss tear)
- Previous peptic ulcer disease or gastritis
- Known or previous h.pylori infection
- Alcohol (not direct pointer to varices as bleeding from peptic ulcer disease still more common in this group)
- Medication particularly NSAIDs, aspirin or warfarin (implicated in approximately 20%)
Do a PR early as it may confirm fresh melaena
Identify and resuscitate patients with haemodynamic instability
If there is any evidence of haemodynamic instability then involve senior ED physician.
- High concentration oxygen delivered via a variable deliver mask with reservoir bag
- Two large bore peripheral intravenous cannulae
- Bloods (see investigations)
- Intravenous fluids crystalloid (colloids if known liver disease*) administer 1-2 litres immediately and reassess
- If not improving administer red cells (O-neg if necessary)
- Gastric tube and aspirate stomach widely used in US not in UK.
- Urinary catheter and measure urine volumes
- Urgent referral to senior GI specialist and Critical Care
*No real evidence to back up theoretical risk of sodium load with saline precipitating ascites
Perform a risk assessment
Variceal bleeds are uncommon even in patients with known alcohol related liver disease. Mortality is high and up to 30% of patients with know varices are likely to re-bleed. A variceal bleed is suggested by evidence of decompensated liver disease such as jaundice, ascites or encephalopathy. Known or suspected variceal bleeds should always be considered to be high risk as in hospital mortality is approximately 50%. All patients should be referred for urgent endoscopy and admitted to a critical care area. Prognosis is principally related to the degree of underlying liver disease rather than the extent of bleeding.
The most widely used risk assessment tool is the Rockall score. Rockall et al identified risk factors in 4185 patients with upper GI haemorrhage. The score was validated on a further population of 625 patients and found to predict mortality but not the rate of re-bleeding.
The score consists of three clinical parameters (age, presence of shock and co-morbidity) and two parameters that rely on endoscopic findings (blood and diagnosis). The maximum pre-endoscopy Rockall score is 7 and post-endoscopy 11. A Rockall score of 3 before endoscopy approximates with a 10% mortality rate and a score of 6 a 50% mortality rate . The main disadvantage of the Rockall score is that it requires findings at endoscopy to calculate all the components of the score. However, the modified pre-endoscopy score is widely used in the UK.
Cardiac failure or IHD
Renal failure, liver failure or disseminated malignancy
No blood or dark spot only
Blood in upper GI tract, adherent clot or spurting vessel
All other diagnoses
GI tract malignancy
The Blatchford score was designed to predict the need for subsequent treatment. This score is more complex than the Rockall although does not include findings at endoscopy.
Blood urea (mmol/L)
Haemoglobin (g/L) for men
Haemoglobin (g/L) for women
Systolic blood pressure (mmHg)
A recent study, comparing the Blatchford and Rockall scores, reported that the Blatchford score identified more high risk bleeds than the Rockall score. There is little evidence to support the use of either the Rockall or Blatchford scores to identify patients with low risk upper GI haemorrhage who may be potentially discharged from the ED without pre-discharge endoscopy.
Both the Blatchford and Rockall scores are useful tools in identifying high risk upper GI bleeds. Rockall scores are more widely used in the UK.
Risk is categorised in the following way:
- Very low risk: no objective evidence of GI bleed consider discharge
- Low risk: admit to MAU or observation unit for next day or out-patient endoscopy
- Moderate risk: admit to appropriate inpatient specialty (local protocols) for urgent endoscopy
- High risk: (Rockall Score (pre-endoscopy)=>3): haemodynamic instability, known varices resuscitate, admit to critical care area for emergency endoscopy
Common causes of upper GI bleeding in the UK are shown in the pie chart below.
Peptic ulcer disease is the commonest cause of upper GI bleeding
Upper GI haemorrhage is largely a clinical diagnosis is largely based on the patients history.
- Urea and electrolytes (Urea will be raised after a significant volume bleed)
- Full blood count (Patients should be transfused in HB <10 (ref)
- Coagulation screen (derangement of clotting in liver diseases)
- Liver Function Tests (identifying liver disease)
- Cross Match RCC (type specific or full Cross Match depending on urgency)
- PR and FOB, if no melaena or unsure
- Chest x-ray, 12-lead ECG, arterial blood gases
- Little role for abdominal x-ray unless needed to rule out other diagnoses such as small bowel obstruction
Medical therapy (non-variceal bleeds)
High dose intravenous proton pump inhibitors (PPI)
PPIs, such as pantoprazole (40mg), are widely used. Theoretically, they reduce bleeding by increasing the pH of the acid environment leading to clot stability. They have been shown post-endoscopy to reduce the re-bleeding rate and need for surgery but have no effect on overall mortality. A pragmatic approach is to give high dose PPIs to high risk patients with upper GI bleeds, particularly when a delay to endoscopy is envisaged. Patients without haemodynamic instability or vomiting can be given high dose oral PPIs.
there is little evidence to support the administration of IV PPIs pre-endoscopy although it is reasonable to give them to patients who are medium or high risk after risk assessment
Infusions such as Octreotide are used occasionally in severe acute non-variceal upper GI haemorrhage. Some evidence from poor quality RCTs report a reduction in ongoing bleeding and need for surgery. It may be administered if a delay to endoscopy is likely.
There is little evidence to support the administration of antifibrinolytic agents such as Tranexamic Acid to patients with upper GI haemorrhage even with known liver disease or a coagulation defect.
Medical therapy (variceal bleeds)
Somatostatins and vasopressins
Two classes of drugs are widely used in the management of variceal haemorrhage. These include somatostatins (Octreotide) and vasopressins (Terlipressin). Somatostatins cause a relaxation of vascular smooth muscle and reduce portal venous pressure. Vasopressins cause arterial vasoconstriction, reducing portal venous pressure but at the risk of end-organ ischaemia. A Systematic review has shown no reduction in number of deaths with somatostatins. However, Terlipressin was noted to be safe and effective. Terlipressin has been shown to reduce blood loss from actively bleeding varices and confers a 34% relative risk reduction in risk of mortality. Terlipressin is also more convenient as it can be given as a bolus.
Terlipressin should be given in the ED to any patient with a suspected variceal haemorrhage
A Cochrane review concludes that there is no evidence of efficacy for the administration of Vitamin K in patients with liver disease who have an upper GI haemorrhage.
In patients with known liver disease and upper GI haemorrhage intravenous broad spectrum antibiotics, such as Ceftriaxone, have been shown to reduce mortality by 27% and the incidence of infection by 60%.
Broad spectrum antibiotics should be given early as part of the Emergency Department management of patients with suspected variceal haemorrhage.
Non Medical Therapy-endoscopy
Endoscopy is the gold standard for diagnosing and treating upper GI haemorrhage. The timing of endoscopy is important. It should not be carried out until the patient is adequately resuscitated. Common endoscopic treatments include injection or thermal therapy for a bleeding peptic ulcer or banding of oesophageal varices. Endoscopy controls bleeding initially in around 90% of patients with bleeding peptic ulcers.Mallory Weiss tears normally stop without endoscopic intervention.Patients should be referred for an urgent endoscopy if they have a Rockall score of 3 or more (risk of death >10%), suspected or known varices or evidence of haemodynamic instability. Patients who are stable can be admitted to a medical ward or observation unit for next-day endoscopy.
High risk bleeds need urgent endoscopy both for diagnosis and therapy
Non Medical Therapy Balloon Tamponade
Balloon tamponade via the insertion of a Sengstaken or Minnesota tube should be undertaken in patients with variceal haemorrhage when the patient continues to bleed heavily despite medical therapy orhas an acute massive variceal bleed and endoscopy is not immediately available. (strong recommendation) Tamponade provides good control of bleeding in 90% of patients although most will re-bleed within 24 hours. The main role of the Sengstaken and Minnesota tubes is to buy time to endoscopy and this can be life-saving. The Sengsataken Blakemore tube has 3 lumens (2 balloons and 1 aspiration port) compared to the Minnesota tube which has 4 (2 balloons and 2 aspiration ports).
- An RSI should be performed and the patient should be intubated to prevent aspiration
- Inflate and deflate the gastric balloon to make sure there is no air leak
- Apply KY jelly onto the tube and pass for 60cm
- Insert air into the gastric aspiration port and listen with a stethoscope over the epigastric area
- Gently inflate the gastric balloon with 400mls of air stopping if there is resistance
- Clamp the gastric balloon port and insert the peg
- Pull the tube back until the balloon lodges at the gastro-oesophageal junction
- Do not inflate the oesophageal balloon
- Attach a 250ml bag of saline onto the tube and hang over a drip stand to provide a pulley mechanism
- In general, try not to keep in for more than 24 hours and deflate the balloon for a short time every 6 hours
- Oesophageal necrosis and perforation from inflation of oesophageal balloon
- Aspiration if airway not secured first
- Mucosal ulceration from pressure
- Proximal migration of tube causing airway obstruction
Balloon tamponade is an effective method of controlling a variceal haemorrhage until endoscopy can be performed
Non Medical Therapy Further Treatment Options
Further treatment options in patients include surgery in Peptic Ulcer Disease if endoscopy fails to control bleeding, the patient re-bleeds or has increasing transfusion requirements. Transjugular Intrahepatic Portosystemic Shunting (TIPS) is a radiological intervention in which a connection is made between the portal and venous system to reduce portal venous pressure. This procedure may be performed in patients with varices who continue to bleed despite medical and endoscopic therapy.
Prognosis & Followup strategies:
- The mortality from upper GI haemorrhage is still extremely high and in the region of 10%
- The mortality of variceal bleeds alone may reach 50%
- Pre-endoscopic Rockall scoring is a useful risk stratification tool (Grade 2a, recommendation D)
- Patients with a Rockall score of 3 or more have at least a 10% mortality rate and should undergo urgent endoscopy and be admitted to a critical care area (Grade 2a, recommendation D)
- Consider the use of high dose intravenous PPIs to high risk patients with upper GI bleeds despite lack of rigorous evidence of effectiveness (Grade 1c, recommendation D)
- Intravenous Terlipressin and broad spectrum antibiotics should be given to all patients with suspected variceal haemorrhage (Grade 1b, recommendation A)
- Familiarise yourself with Sengstaken/ Minnesota tubes you will need to insert one at some point! (Grade 4, recommendation D)
Safety pearls and Pitfalls:
- In a shocked patient with no apparent cause perform a rectal exam early to detect melaena
- Failure to secure the airway before inserting a Sengstaken tube can lead to aspiration
- Failure to recognise those patients that need urgent referral for endoscopy
- All patients with haemodynamic abnormalites or a Rockall score of 3 or more should be referred for admission to a critical care area
- Look for evidence of decompensated liver disease to suggest variceal haemorrhage
- Beware the patient with unexplained postural hypotension or syncope assess for unrecognised GI haemorrhage
- Even in patients with known alcoholic liver disease, bleeding peptic ulcers are more common than varices
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