Upper GI Bleed
Last updated 10th December 2021 - Tom Heaton
Definition
Blood loss within the GI tract occuring between the oesophagus and the ligament of Treitz
This is a good introductory video from Armando Hasudungan: https://www.youtube.com/watch?v=cS4Nz6FuEjw
This is a good introductory video from Armando Hasudungan: https://www.youtube.com/watch?v=cS4Nz6FuEjw
Aetiology
- PUD
- Gastritis
- Oesophagitis
- Duodenitis
- Varices
- Malignancy
- Mallory-Weiss tear
- Vascular malformation
- Portal hypertensive gastropathy
Presentation
May present with:
Additional parts of the history are important to assess:
- Bleeding
- Haematemesis
- Coffee-ground vomiting
- Meleana
- Fresh PR
- Abdominal pain
- Syncope/presyncope/collapse
- Vomiting history
Additional parts of the history are important to assess:
- Drug history.
- NSAIDs
- Steroids
- Anticoagulant/antiplatelets
- Alcohol history.
Assessment
Bloods
Endoscopy
Will provide information on diagnosis and treatment.
Timing is important (below)
Radiology
Angiography is less useful than with lower GI bleeding but may be indicated in some scenarios.
- FBC
- Coag
- G&S
- ABG
- U&E
- LFTs
Endoscopy
Will provide information on diagnosis and treatment.
Timing is important (below)
Radiology
Angiography is less useful than with lower GI bleeding but may be indicated in some scenarios.
Risk Assessment
Goal is to determine:
High Risk
Glasgow-Blatchford Score
Sensitivity >90% (99.6% in one study)
40-50% specificity
A score of 0 suggests low risk and safe for OP assessment - there is a suggestion that a score of 1 may also be safe.
https://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs
Rockall Score
This scoring system is used to assess the risk group of the patient.
Has clinical and post endoscopy components.
The pre-endoscopy calculation can guide the urgency of investigation.
The Glasgow-Blatchford score performs better at detecting the low risk group (safe for discharge).
https://www.mdcalc.com/rockall-score-upper-gi-bleeding-pre-endoscopy
https://www.mdcalc.com/rockall-score-upper-gi-bleeding-complete
This is a good podcast discussing the assessment: https://theresusroom.co.uk/gi-bleed/
High Risk
- Mortality
- Location of care
- Risk of rebleed
- Urgent investigation
- May be investigated as OP
Glasgow-Blatchford Score
Sensitivity >90% (99.6% in one study)
40-50% specificity
A score of 0 suggests low risk and safe for OP assessment - there is a suggestion that a score of 1 may also be safe.
https://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs
Rockall Score
This scoring system is used to assess the risk group of the patient.
Has clinical and post endoscopy components.
The pre-endoscopy calculation can guide the urgency of investigation.
The Glasgow-Blatchford score performs better at detecting the low risk group (safe for discharge).
https://www.mdcalc.com/rockall-score-upper-gi-bleeding-pre-endoscopy
https://www.mdcalc.com/rockall-score-upper-gi-bleeding-complete
This is a good podcast discussing the assessment: https://theresusroom.co.uk/gi-bleed/
Management
Components of management are:
A particular differentiation is variceal vs non-variceal.
Specialist gastroenterology input will form an important part of both management advice and specific interventions.
Resuscitation
This may be part of the assessment of acutely unwell patients i.e. A to E approach
Specific points to consider for massive UGIB include:
Transfusion
A resuscitative approach to transfusion should be used in massive bleeding i.e. massive transfusion protocols.
In other scenarios, a restrictive approach is advised.
Thresholds:
Importantly a restrictive Hb target (7) shows better outcomes:
However, this is clearly not relevant for patients with massive upper GI bleed who should be managed using a massive transfusion approach.
FFP is recommended for correction of coagulopathy in bleeding.
PCC should be used to correct patients on warfarin who are actively bleeding.
- Resuscitation
- Supportive care
- Endoscopy - investigation and treatment
- Medical management
A particular differentiation is variceal vs non-variceal.
Specialist gastroenterology input will form an important part of both management advice and specific interventions.
Resuscitation
This may be part of the assessment of acutely unwell patients i.e. A to E approach
Specific points to consider for massive UGIB include:
- I&V may be needed to protect airway when there is associated neurological compromise
- Large bore IV access should be obtained
- Massive transfusion protocols may need activation
- Balloon tamponade may be part of resuscitation in variceal haemorrhage
Transfusion
A resuscitative approach to transfusion should be used in massive bleeding i.e. massive transfusion protocols.
In other scenarios, a restrictive approach is advised.
Thresholds:
- Hb - 7 g/DL
- Platelets - 50 x 10^9/L
- INR - 1.5
- Fibrinogen - 1 g/L
Importantly a restrictive Hb target (7) shows better outcomes:
- Lower transfusion rates
- Lower mortality
- Lower rebleeding
However, this is clearly not relevant for patients with massive upper GI bleed who should be managed using a massive transfusion approach.
FFP is recommended for correction of coagulopathy in bleeding.
PCC should be used to correct patients on warfarin who are actively bleeding.
Other
Prokinetic
Administration of prokinetics may aid gastric emptying, benefiting endoscopy.
One study suggested erythromycin translated into some better outcomes.
Antacid
Antacid therapy doesn’t appear to make an outcome difference if given pre-endoscopy.
However, there is evidence that it improves visualisation of any bleeding point at endoscopy.
Alongside the intuitive sense to treat the underlying problem, many clinicians would commence an antacid if there is going to be any sort of delay to endoscopy.
PPI is recommended post endoscopy in patients with PUD - given IV.
Those with high risk features at endoscopy benefit from a high dose therapy regime - 80mg bolus with 8mg/hr for 72hr.
PPIs appear to be better than H2RBs
Antiplatelets
Aspirin for secondary prevention should be continued in patients with upper GI bleeding (assuming control of bleeding has been achieved).
The benefits of this continued effect appear to outweigh any increased bleeding risks (there is a threefold increase in cardiovascular events in those whom it is stopped).
Patients at high risk of cardiovascular events on other antiplatelet agents (e.g. clopidogrel) should have specialist discussion.
Other agents (e.g. NSAIDs) should be stopped.
Administration of prokinetics may aid gastric emptying, benefiting endoscopy.
One study suggested erythromycin translated into some better outcomes.
Antacid
Antacid therapy doesn’t appear to make an outcome difference if given pre-endoscopy.
However, there is evidence that it improves visualisation of any bleeding point at endoscopy.
Alongside the intuitive sense to treat the underlying problem, many clinicians would commence an antacid if there is going to be any sort of delay to endoscopy.
PPI is recommended post endoscopy in patients with PUD - given IV.
Those with high risk features at endoscopy benefit from a high dose therapy regime - 80mg bolus with 8mg/hr for 72hr.
PPIs appear to be better than H2RBs
Antiplatelets
Aspirin for secondary prevention should be continued in patients with upper GI bleeding (assuming control of bleeding has been achieved).
The benefits of this continued effect appear to outweigh any increased bleeding risks (there is a threefold increase in cardiovascular events in those whom it is stopped).
Patients at high risk of cardiovascular events on other antiplatelet agents (e.g. clopidogrel) should have specialist discussion.
Other agents (e.g. NSAIDs) should be stopped.
Endoscopy
Immediately in unstable patients with severe UGIB, after resuscitation.
Within 24h for other patients admitted with UGIB.
Some risk factors that suggest need for urgent endoscopy:
As well as identification of the source of bleeding, intervention may be possible via the endoscope:
PUD:
Subsequent management is dependent on findings and may involve:
Within 24h for other patients admitted with UGIB.
Some risk factors that suggest need for urgent endoscopy:
- Syncope
- Hypotension
- Major transfusion (>4 units)
- Haematemesis
As well as identification of the source of bleeding, intervention may be possible via the endoscope:
PUD:
- Adrenaline injections
- Clipping
- Heat coagulation
- Banding
- Sclerotherapy
Subsequent management is dependent on findings and may involve:
- H. Pylori treatment
- Medication review
- Antacid therapy
Incidence
84-172/100,000 adult/year
Upper GIB is about 4 times as common as a lower source.
Mortality:
Presents with UGIB - 7%
Bleeding as IP - 30%
Upper GIB is about 4 times as common as a lower source.
Mortality:
Presents with UGIB - 7%
Bleeding as IP - 30%
Variceal Bleeding
Variceal bleeding is recognised as a specific subset of upper GI bleeding.
This arises from varices, high pressure venous vessels that are connected to the portal venous system.
The high resistance to blood flow within a cirrhotic liver increases portal venous pressure and leads to venous dilatation.
This ongoing resistance to flow can result in the blood flow utilising other means of reaching the systemic circulation, termed portosystemic shunts, a major route being those found in the oesophagus.
These dilate as there is an increase in blood flow and pressure beyond what these vessels are able to cope with.
Subsequent bleeds can therefore occur under not insignificant pressure (because of the portal hypertension) and blood loss can be rapid.
It is important to note that variceal bleeding can be a precipitant for other cirrhosis complications e.g. encephalopathy.
This arises from varices, high pressure venous vessels that are connected to the portal venous system.
The high resistance to blood flow within a cirrhotic liver increases portal venous pressure and leads to venous dilatation.
This ongoing resistance to flow can result in the blood flow utilising other means of reaching the systemic circulation, termed portosystemic shunts, a major route being those found in the oesophagus.
These dilate as there is an increase in blood flow and pressure beyond what these vessels are able to cope with.
Subsequent bleeds can therefore occur under not insignificant pressure (because of the portal hypertension) and blood loss can be rapid.
It is important to note that variceal bleeding can be a precipitant for other cirrhosis complications e.g. encephalopathy.
Management
The general principles will be much the same as those described above.
High consideration to management of coagulation must be an especially important feature of the resuscitation of these patients given the common association with the underlying disease.
Key specific features include:
Terlipressin
Terlipressin is a splanchnic vasoconstrictor that reduces portal blood flow and thus can improve variceal bleeding.
It should be started in patients with suspected variceal GI bleeding.
The dose is 2mg IV 4 times a day for up to 5 days or until haemostasis is achieved.
Octreotide (a long acting somatostatin analogue) is an alternative here.
The BSG guidance makes a strong recommendation for this noting a relative risk reduction in all cause mortality of 34%.
Antibiotics
IV antibiotics are also recommended to be given routinely in suspected variceal bleeding as prophylaxis.
These patients have a high risk of concomitant bacterial infection and standardised antibiotic administration reduces mortality, length of stay and rebleeding rates.
The evidence favours IV over the oral route here.
The choice of antibiotic will usually be led by local policy e.g. ceftriaxone.
Endoscopy
This will often be the diagnostic component as well as the major therapeutic option.
Endoscopy will usually reveal the characteristic tortuous vessels, although intense bleeding can make it challenging.
Band treatment (ligation) suggests better outcomes compared to sclerotherapy.
High consideration to management of coagulation must be an especially important feature of the resuscitation of these patients given the common association with the underlying disease.
Key specific features include:
- Splanchnic vasoconstrictor
- Prophylactic antibiotics
- Endoscopy
Terlipressin
Terlipressin is a splanchnic vasoconstrictor that reduces portal blood flow and thus can improve variceal bleeding.
It should be started in patients with suspected variceal GI bleeding.
The dose is 2mg IV 4 times a day for up to 5 days or until haemostasis is achieved.
Octreotide (a long acting somatostatin analogue) is an alternative here.
The BSG guidance makes a strong recommendation for this noting a relative risk reduction in all cause mortality of 34%.
Antibiotics
IV antibiotics are also recommended to be given routinely in suspected variceal bleeding as prophylaxis.
These patients have a high risk of concomitant bacterial infection and standardised antibiotic administration reduces mortality, length of stay and rebleeding rates.
The evidence favours IV over the oral route here.
The choice of antibiotic will usually be led by local policy e.g. ceftriaxone.
Endoscopy
This will often be the diagnostic component as well as the major therapeutic option.
Endoscopy will usually reveal the characteristic tortuous vessels, although intense bleeding can make it challenging.
Band treatment (ligation) suggests better outcomes compared to sclerotherapy.
Rescue Therapy
Balloon Tamponade
This is a last resort when unable to control bleeding through other means.
A specially designed tube (Sengstaken-Blakemore) is inserted into the oesophagus and into the stomach.
With inflation the pressure effect will hopefully allow a tamponading effect and stop ongoing haemorrhage.
The initial pressure is directed through a gastric balloon with traction then being applied to try and tamponade vessels passing up from the stomach.
If this fails, tamponade can be tried using the esophageal balloon.
It is not without its complications, including oesophageal rupture, especially if used when unfamiliar with it.
This is a really good video on insertion and use:
https://www.youtube.com/watch?v=NHelCd5Jtp4
In quick summary:
TIPS
TIPS stands for transjugular intrahepatic portosystemic shunt.
This involves the vascular bypassing of the highly resistant, cirrhotic liver.
The improved flow allows reduction in portal pressure and reduces variceal bleeding, especially in refractory cases.
However, the loss of the metabolic activity of the liver on portal blood means a high delivery of adverse products to the circulation and there is a high rate of encephalopathy.
As such it is primarily used as a last resort therapy in the acute setting, although it does have a role in refractory ascites or varices in the elective setting too.
Other shunt procedures are also potential options.
This is a last resort when unable to control bleeding through other means.
A specially designed tube (Sengstaken-Blakemore) is inserted into the oesophagus and into the stomach.
With inflation the pressure effect will hopefully allow a tamponading effect and stop ongoing haemorrhage.
The initial pressure is directed through a gastric balloon with traction then being applied to try and tamponade vessels passing up from the stomach.
If this fails, tamponade can be tried using the esophageal balloon.
It is not without its complications, including oesophageal rupture, especially if used when unfamiliar with it.
This is a really good video on insertion and use:
https://www.youtube.com/watch?v=NHelCd5Jtp4
In quick summary:
- Insert
- Fill gastric port with 250ml
- Apply traction - 250-500g
- Inflate oesophageal balloon only if needed.
TIPS
TIPS stands for transjugular intrahepatic portosystemic shunt.
This involves the vascular bypassing of the highly resistant, cirrhotic liver.
The improved flow allows reduction in portal pressure and reduces variceal bleeding, especially in refractory cases.
However, the loss of the metabolic activity of the liver on portal blood means a high delivery of adverse products to the circulation and there is a high rate of encephalopathy.
As such it is primarily used as a last resort therapy in the acute setting, although it does have a role in refractory ascites or varices in the elective setting too.
Other shunt procedures are also potential options.
Epidemiology
About 50% of patients will have varices at the time that their cirrhosis is diagnosed.
In addition, about ⅓ of those with varices will develop a bleeding complication at some point.
This is increased to between 60-70% of those with decompensated cirrhosis.
Overall it is the cause of 5-10% of all UGIB.
Mortality is closely relates to
Risk of death is highest in the first few days after a bleed, then slowly decreases.
Rebleed rates can be as high as 70% and associated with worse outcomes.
Beta blockers may be used a preventative therapy in those at moderate to high risk of bleeding or as secondary prevention.
In addition, about ⅓ of those with varices will develop a bleeding complication at some point.
This is increased to between 60-70% of those with decompensated cirrhosis.
Overall it is the cause of 5-10% of all UGIB.
Mortality is closely relates to
- Severity of liver disease
- Severity of bleeding
- AKI
Risk of death is highest in the first few days after a bleed, then slowly decreases.
Rebleed rates can be as high as 70% and associated with worse outcomes.
Beta blockers may be used a preventative therapy in those at moderate to high risk of bleeding or as secondary prevention.
Links & References
- Henderson, G. Upper gastrointestinal bleeding. Patient.info. 2016. https://patient.info/doctor/upper-gastrointestinal-bleeding-includes-rockall-score
- Northwest ICM Teaching. 2019
- Hasudungan, A. Upper GI bleed causes - overview. Youtube. 2016. https://www.youtube.com/watch?v=cS4Nz6FuEjw
- Nickson, C. Gastrointestinal haemorrhage. LITFL. 2019. https://litfl.com/gastrointestinal-haemorrhage/
- The Resus Room. Upper GI Bleed. 2016. https://theresusroom.co.uk/gi-bleed/
- NICE. Acute upper gastrointestinal bleed in over 16s: management. CG141. 2012. Available at https://www.nice.org.uk/guidance/cg141 [link]
- Tripathi D et al. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. 2015. Gut. Available at: http://gut.bmj.com/content/early/2015/05/12/gutjnl-2015-309262.full.pdf+html [link]
- Sung, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann Intern Med. 2010 Jan 5;152(1):1-9. https://pubmed.ncbi.nlm.nih.gov/19949136/
- British Society of Gastroenterology. Acute upper GI bleed care bundle. 2020. https://www.bsg.org.uk/clinical-resource/bsge-acute-upper-gi-bleed-care-bundle/
- Henderson, R. Oesophageal varices. Patient.info. 2016. https://patient.info/doctor/oesophageal-varices
- Strong Medicine. Esophageal varices and variceal hemorrhage. Youtube. 2019. https://www.youtube.com/watch?v=DYYHPWj7gfw
