Upper GI Bleed
Last updated 30th June 2019 - 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
- Haematemesis
- Abdominal pain
- Syncope/presyncope/collapse
- Vomiting history
Additional parts of the history are important to assess:
- Drug history.
- NSAIDs
- Steroids
- NSAIDs
- 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.
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:
RCT - Restrictive Hb target (7) shows better outcomes:
FFP is recommended for correction of coagulopathy in bleeding.
PCC should be used to correct patients on warfarin who are actively bleeding.
Prokinetic
Administration of prokinetics may aid gastric emptying, benefiting endoscopy.
One study suggested erythromycin translated into some better outcomes.
Antacid
PPI doesn’t appear to make a difference pre-endoscopy.
PPI is recommended post endoscopy in patients with PUD - given IV
PPIs appear to be better than H2RBs
- Resuscitation
- Supportive care
- Endoscopy - investigation and treatment
- Medical management
A particular differentiation is variceal vs non-variceal.
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
RCT - Restrictive Hb target (7) shows better outcomes:
- Lower transfusion rates
- Lower mortality
- Lower rebleeding
FFP is recommended for correction of coagulopathy in bleeding.
PCC should be used to correct patients on warfarin who are actively bleeding.
Prokinetic
Administration of prokinetics may aid gastric emptying, benefiting endoscopy.
One study suggested erythromycin translated into some better outcomes.
Antacid
PPI doesn’t appear to make a difference pre-endoscopy.
PPI is recommended post endoscopy in patients with PUD - given IV
PPIs appear to be better than H2RBs
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%
Links & References
- Henderson, G. Upper gastrointestinal bleeding. Patient.info. 2016. https://patient.info/doctor/upper-gastrointestinal-bleeding-includes-rockall-score
- Stepping Hill Teaching
- 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/
