Acute upper GI bleeding: assessment and management in the first 24 hrs

Dr Sarah Hearnshaw Consultant Gastroenterologist Royal Victoria Infirmary Newcastle upon Tyne What do you think?

• Brilliant – I love GI bleeders • AAHHHH – can someone else see this one please? • Oh no – I’m going to have to ring a grumpy gastroenterologist • Oh no – bleeders are serious • I can handle this – there’s nothing I can do to make it worse really….. Objectives • Help you all love patients with AUGIB

• Help you believe it’s important and easy

• Learn (evidence-based) early care

• Prevent you getting a grumpy gastroenterologist AUGIB in UK

1993 2007 2015* Mortality 14 10 10 Re-bleeding rates 16 13 23 % varices 4 8 8

* NCEPOD study looked at higher risk bleeders - all had had 3u blood – and we now know blood increases re-bleeding and death Presenting symptoms

• Haematemesis • Melaena • Syncope • Fresh blood PR • Coffee ground vomit (if no other cause) Patient Details / Label 2018 UK AUGIB Bundle Name: DOB: (to be performed within 24h) HospitalDate: No.:

If reported: RECOGNITION Haematemesis, melaena or coffee ground

Trigger bundle and record if performed Y/ N/ NA Perform NEWS as indicated RESUSCITATION Commence IV crystalloid Transfuse if Hb <70g/L, aim for 70-100g/L

RISK Calculate Glasgow-Blatchford Score (GBS): enter value ASSESSMENT  Consider discharge if GBS 0 or 1

If cirrhosis/suspected variceal bleed, give terlipressin 2mg QDS and antibiotics as per local protocol Rx Continue aspirin Suspend all other antithrombotics

Referral for endoscopy to be undertaken within 24h of presentation

REFER Refer to GI specialist if varices or requiring therapeutic endoscopy

Review endoscopy report REVIEW PPI if high risk ulcer post endoscopy Post-haemostasis antithrombotic plan

Haemodynamic instability? Think Major Haemorrhage Protocol +/- critical care review Case 1

• 79 female, melaena two • IHD, T2DM, OA days, • BP 100/60, HR 96, pale • Clopidogrel, metformin, but chatty celecoxib, sertraline, • Hb 77, Urea 15, PT 14 lansoprazole

What would you do now? Resuscitate first

• Caution in elderly • Caution in heart failure • But do not wait….. Which fluids when?

• Cochrane Reviews – Crystalloids for all1, balanced, 500ml over 15 minutes – No benefit of albumin (some harm)2 • Varices and CLD – Resuscitation is what matters – Crystalloids, blood, not FFP or colloids – Not 5% dextrose ()

1Roberts I, Alderson P, Bunn F, et al. Cochrane Database of Systematic Reviews 2004 2Alderson P, Bunn F, Li Wan Po A et al. Cochrane Database of Systematic Reviews 1998 Resuscitation in AUGIB

• To reduce risk of death and minimise end-organ damage

• Different to trauma and e.g. AAA patients

• Aims: – get to endoscopy to turn off tap – minimise risk from co-morbid disease Risk assessment • Identify who can go home

• Stratify who needs urgent attention

• Does not replace “end of bed” test

• Makes you do all the important tests

• Glasgow Blatchford Score most common and best “high risk” …don’t need a score Glasgow Blatchford Score (GBS): to predict need for intervention or death Blatchford et al, Lancet 2000;356:1318-21

Identifying those at low risk (GBS=0):

• urea < 6.5 mmol/l PREDICTS NEED FOR INTERVENTION• Hb > 130 g/l men > 120 g/l women • systolic BP >110mmHg • pulse < 100/min

• No melaena, syncope, CCF, disease Out-patient management of patients with low- risk UGIB: can we safely extend the GBS? Z Mustafa et al. Eur J Gastro Hep 2015;27:512-15 ESGE guideline: 2015

• Recommend use of GBS pre-scope

• Patients with GBS of 0-1 do not require early ‘scope or admission International prospective study comparing risk scores in UGIB AJ Stanley, et al. BMJ 2017;356:i6432

GBS≤1 identifies 19% patients at very low risk – can be managed as OP Back to our lady

• GBS – Melaena - 1 – Urea - 4 – Hb – 6 – BP 1

BP improved with 500ml saline and HR reduced Intermittent melaena Blood transfusion in AUGIB

• UK 2007 audit: 50% transfused when Hb 80- 100g/L • Excessive transfusion - increased re-bleeding (obs. studies) - reactions & cost • Spanish & UK RCTs suggest restrictive is best Villanueva et al, NEJM 2013;368:11-21 Jairath et al, Lancet 2015;386:137-44 Transfusion for upper GI bleeding Villanueva et al, N Engl J Med 2013;368:11-21 Timing of Endoscopy Association between timing & mortality in haemodynamically stable patients (n=9668)

p<0.001

ASA: American Society of Anesthesiologists S Laursen et al. GI Endosc 2017;85:936-44 Association between timing & mortality in patients with haemodynamically instability (n=2933)

p<0.035

ASA: American Society of Anesthesiologists S Laursen et al. GI Endosc 2017;85:936-44 Timing of endoscopy: summary

• Aim for endoscopy <24hrs - unless very low-risk: for OP endoscopy - unless unstable: (ASAP) after resus

• …if ASA 3-5 or haemodynamic instability, consider delaying endoscopy 6-12 hours to optimise resuscitation & co-morbidities*

* May mean endoscopy is best done in middle of night Back to our lady…..

• 500ml crystalloid quickly for BP • Kept NBM with further background IVT • 1u blood, stable overnight • OGD next morning (11 hours after presenting) – Large DU, dual endoscopic therapy – 72 hrs iv PPI – HP eradication • Clopidogrel re-started next day

Re-bleeding

Resuscitate Repeat OGD

Non-variceal Variceal

IR or surgery SB tube +- TIPSS

Repeat OGD 6 weeks GO-UD 2-3 weeks Varices Summary • GI bleeding care bundle • Resuscitate & Risk assess (GBS ≤1) • Restrictive Transfusion • No robust benefit from pre-scope PPIs (TXA data awaited) • Scope all admitted patients within 24hrs Some trickier ones….. • 81 female, recent discharge # NOF – post-op NSTEMI – post-op small peripheral PEs; rivaroxaban. • Discharged on: – clopidogrel, aspirin, Rivaroxaban, bisoprolol and lansoprazole. • Two days of melaena witnessed in ED at 0900 • BP 103/65 • Bloods Hb 93; urea 23. PT normal. • 66 male, in-patient post TKR. • Known NASH cirrhosis but no known varices. • Haematemesis, melaena, 3 days post op (admission). BP 94/60 • Looks awful, not jaundiced but confused and sleepy (has been on codeine and paracetamol post-op, no NSAIDs in hospital). On prophylactic tinz and TEDS. • Hb 66, urea 10.5, PT 10, Bili 54, Alb 30, Creat 100, MCV 94. • 59 female, bipolar, lives alone, Jehovah’s witness. Arrives in EAU at 1400. • Melaena 3 days, syncope • Hb 98, Urea 15, creat normal, PT normal. BP 100/70 • Given 1l fluid in ED • Alert orientated, formal documentation to decline blood products and confirms this. • On aspirin for previous TIA and PPI Questions?