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Upper GI bleed

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Variceal haemorrhage

Aetiology

Major causes

  • peptic ulcer disease
  • oesophageal and gastric varices
  • gastritis
  • oesophagitis
  • duodenitis
  • Mallory-Weiss tear
  • angiodysplasia
  • upper GI malignancy
  • anastamotic ulcers
  • Dieulafoy lesion (congenital submucosal artery)

Other important causes

  • aortoenteric fistula
  • portal hypertensive gastropathy

Clinical assessment

Key questions:

  • How severe?
    • Assess from the severity of shock
  • Acute or chronic?
  • Still bleeding?
  • Variceal or non-variceal bleeding?
  • Associated coagulopathy?

Clues to aetiology from history

Aetiology History
Varices, portal gastropathy Alcoholism, cirrhosis, Hepatitis B
Peptic ulcer Epigastric or RUQ pain, NSAID or aspirin use
Stress gastritis Critical illness preceding bleeding
Mallory Weiss tear Vomiting prior to haematemesis, alcoholism
Malignancy Recent involuntary weight loss, dysphagia, cachexia, early satiety
Aorto-enteric fistula Aortic aneurysm, prior abdominal aortic aneurysm repair

Physical examination

Directed at:

  • Assessing severity of shock
  • GI examination
    • Abdominal tenderness?
      • Unusual in uncomplicated GI bleeding, except occasionally with peptic ulcer disease
      • Severe tenderness suggests GI bleeding associated with bowel ischaemia, obstruction or perforation
    • Bowel sounds
      • Hyperactive bowel sounds usual - blood in proximal gut stimulates peristalsis
      • Normal bowel sounds suggest lower GI bleeding
      • Hypoactive bowel sounds - suggest bowel ischaemia, ileus or obstruction
    • Signs of chronic liver disease or portal hypertension?
      • hepatomegaly
      • splenomegaly
      • palmar erythema
      • caput medusa
      • spider naevi
      • peripheral oedema
      • ascites
    • Rectal examination
      • blood?
      • melaena?
      • haemorrhoids or fissures?

Nasogastric aspiration

  • frankly bloody aspirate - on-going upper GI bleeding
  • coffee grounds - recent upper GI bleeding
  • absence of blood or coffee grounds does not exclude upper GI bleed - duodenal bleeding with a closed pylorus will not result in blood or coffee grounds in the stomach. However, if there is bile in the nasogastric aspirate it suggests that reflux from the duodenum into the stomach is occurring. In this case the absence of blood or coffee grounds in the aspirate suggests that the bleeding is not from the upper GI tract or stopped many hours earlier

Investigations

  • complete blood count - useful for comparison of serial values. Initial haemoglobin concentration may be normal if taken early, before haemodilution has taken place
  • liver function tests
  • renal function tests - urea may be raised out of proportion to creatinine
  • clotting
  • serial ECGs and cardiac enzymes to exclude myocardial infarction (complicates ~10% of severe GI bleeds)
  • urgent endoscopy (<12 h) for all patients requiring ICU admission for GI bleeding

Treatment

Fluid resuscitation

  • give blood, FFP and platelets in a 1:1:1 or 2:1:1 ratio for patients with massive bleeding to prevent dilutional thrombocytopaenia and coagulopathy
  • beware over-transfusion, particularly in patients with variceal bleeding in whom over-transfusion may result in a significant rise in portal pressure

Pharmacotherapy

  • Proton pump inhibitor (IV)
    • start even before endoscopy
    • reduces risk of re-bleeding, need for surgery and need for transfusion but not mortality
    • benefit greatest for those at high risk of recurrent bleeding, who should receive continuous infusion
  • Octreotide
    • somatostatin analogue
    • inhibits glucagon-induced mesenteric vasodilatation

Endoscopy

  • investigation and intervention of choice
  • variety of endoscopic interventions can be used to stop bleeding
  • complications include:
    • GI perforation
    • precipitation of bleeding
    • missed pathology
    • aspiration
  • features of peptic ulcer associated with recurrent bleeding:
    • spurting or oozing 85-90% risk of rebleeding
    • protruberant vessel 35-55%
    • adherent clot 30-40%
    • flat pigmented spot on ulcer base 5-10%

Embolization

  • angiographic embolization is now treatment of choice for those patients in whom endoscopic treatment is unsuccessful
  • angiography can usually successfully locate the site of bleeding when:
    • haemorrhage is severe enough to cause shock
    • transfusion requirement 3 units per 24h
    • active haemorrhage seen endoscopically
  • complications include:
    • adverse effects of contrast
    • puncture-related complications
      • haematoma
      • arterial thrombosis or dissection
    • bowel ischaemia (5% of patients)

Surgery

  • Generally the last resort

Disease specific treatment

Infections

Presentation with GI bleeding indicates severe disease

  • Candida albicans: fluconazole or echinocandin
  • Cytomegalovirus: ganciclovir
  • Herpes simplex virus: acyclovir

Helicobacter pylori
Diagnosed with endoscopic biopsy or urease testing usually, in the context of GI bleeding. First line therapy is combination therapy with proton pump inhibitor, amoxicillin and clarithromycin.

Oesophageal variceal bleeding

Click here

Further reading

Busch ORC et al. Therapeutic options for endoscopic haemostatic failures: the place of the surgeon and radiologist in gastrointestinal tract bleeding. Best Practice & Research Clinical Gastroenterology, 2008; 22(2):341-54

Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin N Am, 2008; 92:491-509


©Charles Gomersall, February, 2015 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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