Updates in the management of Upper GI Bleed
By Dr. Fawziah Alsalmi
Background on UGIB:
Upper gastrointestinal bleeding remains a common Medical Emergency with a major cause of Morbidity and Mortality. Predictors for UGIB including a patient reported history of melena, melenic stool on examination, a nasogastric lavage with blood or coffee grounds, and a serum urea nitrogen:creatinine ratio of more than 30.1 Factors increasing mortality include re-bleeding, age over 60 and the finding of blood in the stomach during endoscopy.
Risk of re-bleeding increase with melena, identification of a gastric or duodenal ulcer, endoscopic stigmata of hemorrhage such as blood, clot, and active bleeding, and the finding of shock on admission.2
Presence of blood on Nasogastric tube , tachycardia or HB level less than 8 g/dL are indicators for sever UGIB requiring Urgent intervention.2
Types of Presentations :
– UGIB : hematemesis , melena or bright red blood per rectum in case of active rapid UGIB
– Occult GIB : patient presented with relative anemia and guaiac positive stool ( source can be UGIB or LGIB )
– Severe Abdominal pain is an unusual presentation of GIB and a diagnosis of a surgical abdomen should be considered (ischemic,infectious colitis or perforation) with an appropriate radiographic confirmation if needed.
Management of UGIB :
-The initial evaluation of patients with acute upper GI bleeding involves an assessment the airway, hemodynamic stability and resuscitation as needed, risk stratification and diagnostic studies (usually endoscopy) with the goal of both diagnosis and treatment of the underlying cause.
– In addition to initial resuscitative measures, there are interventions that have shown to be helpful in the management of UGIB like PPI (Proton Pump Inhibitor), Octreotide, prophylactic Antibiotics among others.
But What is the evidence behind these lines of management and their impact on morbidity and mortality?
Nasogastric lavage is associated with earlier performance of endoscopy, but NO difference in clinical outcomes (30 days Mortality , Blood transfusion requirements, Length of stay or surgery),a clear aspirate can still miss almost 15% of high risk lesions.3
In patients presenting with an upper gastrointestinal (GI) bleed,restrictive transfusion strategy (transfusion when HB level less than 7g/dl) significantly reduce mortality in comparison to the liberal transfusion strategy (5% vs. 9%, P=0.02) which can also decrease risk of re-bleeding, the need for rescue therapy and rate of complications.
Correction of underlying coagulopathy should not delay endoscopy. Consider correction
of coagulopathy in patients receiving anticoagulants with suprathreputic INR. A presentation
with INR of 1.5 or more is a significant predictor of mortality. Correction of coagulopathy from
other causes should be case based.4
Proton pump Inhibitors
PPI treatment initiated before endoscopy for undifferentiated UGIB reduces stigmata of recent hemorrhage and requirement for endoscopic therapy, but doesn’t affect clinically important outcomes namely: mortality, re-bleeding or need for surgery. 5 However, in patients with UGIB secondary to PUD it does decrease risk of re-bleeding and the need for a surgical intervention but doesn’t decrease overall mortality.5
* Somatostatin analogues are splanchnic vasoconstrictors that reduce portal hypertension and the risk of persistent bleeding, re-bleeding, transfusion requirements in patients with variceal bleeding especially if combined with endoscopy. But it doesn’t decrease mortality.6,7
There is a mortality benefit in starting prophylactic antibiotics in cirrhotic patients with UGIB. Multiple trials have proven effectiveness of prophylactic antibiotics suggesting reduction of overall cause of mortality, mortality related to bacterial infections, re-bleeding events and length of stay in the hospital. No specific antibiotic for gram negative infections can be preferred. Therefore, antibiotic selection should be made considering local conditions such as bacterial resistance profile and treatment costs.8
Risk Stratification of UGIB :
– There are multiple scoring systems to identify high vs low risk patients.
– Glasgow-Blatchford and clinical Rockall score identify patients who require an urgent endoscopy by clinical and laboratory factors .
– A complete Rockall score, which relay on both Clinical and endoscopic variables, categorizes patients presenting with UGIB to predict risk of death and re-bleeding.
– The Blatchford score was 99.6% sensitive and the clinical Rockall was 90.2% sensitive in identifying patients as high risk (high-risk patients were defined as those who required a blood transfusion, an endoscopic or surgical interventions during their admission.
– Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.9
Take home points :
– Upper GIB is more common and more serious than LGIB.
– Effective management for UGIB in term of mortality reduction :
* Prophylactic Antibiotics for cirrhotic patients with UGIB
* Restrictive blood transfusion (transfusion when HB <7) but consider higher threshold for patients with underlying ischemic cardiac disease and poor heart function.
– PPI and Somatostatin analogues do not affect mortality.
– Before endoscopy, calculate a Blatchford Score consider discharge if the score is zero.
– After endoscopy, calculate a Rockall Score, this helps determine disposition
– Consider endoscopy for severe acute bleeding immediately after resuscitation