Case-based discussion: 1

History A 65-year-old lady is brought in by ambulance after a 4-hour history of coffee ground vomit. She has a background of severe osteoarthritis of the knees but is otherwise well.

On examination, she has a tender epigastrium. Her reveals black stool.

Observations HR 115, BP 97/45 mmHg, RR 22, SpO2 93%, Temp 37.5

2 Question: 1

3 Case-based discussion: 1

History A 65-year-old lady is brought in by ambulance after a 4-hour history of coffee ground vomit. She has a background of severe osteoarthritis of the knees but is otherwise well.

On examination, she has a tender epigastrium. Her rectal examination reveals black stool.

Observations HR 115, BP 97/45 mmHg, RR 22, SpO2 93%, Temp 37.5

4 Introduction

Definition • Upper gastrointestinal bleeding refers to bleeding originating proximal to the ligament of Treitz (duodenojejunal function) Upper Gastrointestinal Epidemiology tract • 70,000 annual hospital admissions in the UK • Non-variceal origin is most common • Mortality rate: 10% Duodenojejunal junction

(1)

5 Aetiology

Common • (26%) • Oesophageal varices (16%) • Oesophagitis (17%) • Mallory-Weiss tear (3%)

Uncommon • Boerhaave syndrome • Gastric varices • Arteriovenous malformations • Dieulafoy’s lesions

6 Question: 2

7 Question: 3

8 Pathophysiology

Aetiology Mechanism • H. pylori • Aggressive factors overwhelm • NSAIDs protective factors Peptic ulcer disease • Aggressive: acid, pepsin, H. pylori, NSAIDs • Defensive: bicarbonate layer • damage causes portal Oesophageal varices • Increased resistance hypertension • Increased flow • Development of collateral vessels • GORD • Reflux acid irritates the • Medicines e.g. NSAIDs and oesophagus, causing Oesophagitis doxycycline inflammation • Crohn’s disease • Straining, coughing, retching • Sudden rise in abdominal • Hiatus pressure across the gastro- Mallory-Weiss tear • Most diseases that induce oesophageal junction • Distention in oesophageal region

9 Pathophysiology

(2) (3)

10 Differentials

Aetiology Mechanism • Vomiting • Sudden rise in oesophageal pressure during vomiting causes rupture Boerhaave syndrome • Left posterolateral wall of lower oesophagus most commonly affected • Large blood vessels beneath the • Pulsation from large vessel leads gastrointestinal mucosa bleeds to thinning of the mucosa Dieulafoy’s lesions • No abnormality (ulceration or • Vessel becomes exposed erosion)

11 Clinical features Symptoms Signs • Haematemesis • Possible abdominal tenderness • E.g. variceal bleed or +/- peritonism Mallory-Weiss tear

• Coffee-ground vomiting • E.g. peptic ulcer disease or oesophagitis • Melaena • : e.g tachycardia and hypotension • : e.g. epigastric • Chronic : pain in peptic ulcer rupture suggests variceal bleed • Encephalopathy • Scleral icterus • • Chest pain and SOB: • Anaemic features: in particularly Boerhaave chronic cases, e.g. bleeding syndrome tumour

12 Differentials

History Clinical findings Initial investigations • Coffee-ground • Epigastric tenderness • Bloods vomiting • Shock if perforated • H. pylori urea breath • Epigastric pain test Peptic ulcer disease • NSAID or • Erect CXR corticosteroid use • OGD • Previous ulcers • Sudden onset, • Signs of chronic liver • Bloods projectile, significant disease • OGD haematemesis • Shock Oesophageal varices • or other cause of • GORD • ’’ • Bloods Oesophagitis • and • OGD

• Minimal haematemesis • Epigastric tenderness is • Bloods following retching or possible • OGD vomiting • Stable Mallory-Weiss tear • Self-limiting bleeding • Background of alcohol excess 13 Differentials

History Clinical findings Investigations • Severe • Restrosternal +/- • Bloods retching/vomiting à epigastric pain • CXR and CT chest extreme retrosternal • Subcutaneous pain emphysema Boerhaave syndrome • SOB • Fever • Alcohol • Haemodynamically unstable • Surgical emergency

Examples • Bleeding GI tumour

Other important • Arteriovenous causes malformation

• Dieulafoy's lesion

14 Investigations

Primary investigations • FBC: anaemia • LFTs and coagulation profile: assess the severity of liver disease and bleeding risk • U&Es: urea is raised as protein; pre-renal AKI is possible • Crossmatch/group and save: ensures blood is ready for transfusion if needed • Venous blood gas: analysed within minutes and provides an Hb estimate • Raised lactate suggests poor tissue perfusion; associated with a significant bleed • Upper GI endoscopy: diagnostic and therapeutic

Investigations to consider • Erect CXR: if perforation is suspected • : e.g. ruptured peptic ulcer • Pneumomediastinum: e.g. oesophageal rupture • CT chest: if oesophageal rupture is suspected; consider a contrast-enhanced swallow in select cases

15 Investigations

(4) (5)

16 Investigations

(6) (7) 17 Question: 4

18 Glasgow Blatchford Score

Pre-endoscopy risk stratification • Score of 0: consider discharge and return for an outpatient endoscopy • > 0: requires admission for an inpatient endoscopy

Score Score Admission risk factor Admission risk factor value value Blood urea (mmol/L) Systolic blood pressure • 6.5 – 8 2 (mmHg) 1 • 8 – 10 3 • 100 – 109 2 • 10 – 25 4 • 90 – 99 3 • > 25 6 • < 90 Hb (g/L) for men Pulse ≥ 100/minute 1 • 120 – 130 1 • 100 – 120 3 History/co-morbidities • < 100 6 • Presentation with 1 Hb (g/L) for women melaena 2 • 100 – 120 1 • Presentation with 2 • < 100 6 syncope 2 • Hepatic disease • Cardiac failure 19 Investigation pathway

© BiteMedicine (2020) 20 Question: 5

21 Question: 6

22 Management: general principles

ABCDE approach • Patients should ideally be resuscitated prior to endoscopy

IV fluids • Useful if the patient is in shock, but important not to overhydrate as this can cause haemodilution

Blood products: if required • Blood transfusion • Platelet transfusion if PLTs < 50 x109/L • FFP if clotting is deranged • Consider vitamin K

23 Management: bleeding peptic ulcer

First-line • Upper GI endoscopy: diagnostic and therapeutic with one of the following suggested • Clipping +/- adrenaline • Thermal coagulation with adrenaline • Sclerotherapy (fibrin or thrombin injection) with adrenaline • High-dose IV PPI: administered post-endoscopy to reduce rebleeding

Second-line • Surgery or embolisation by interventional radiology: reserved for cases where adequate haemostasis is not achieved at endoscopy

Perforated peptic ulcer • Surgery: usually requires a Graham Omental Patch and a thorough abdominal lavage

24 Management: perforated peptic ulcer

(8) 25 Management: variceal bleed

Further first-line measures • Terlipressin: splanchnic vasoconstriction improves initial haemostasis and prevents rebleeding • Prophylactic antibiotics: all patients should receive antibiotics; quinolones are usually used

If uncontrolled bleeding • Balloon tamponade: conducted in an emergency as a temporary measure if shocked and endoscopy is delayed • A Sengstaken-Blakemore tube can be inserted through the mouth/nose and lowered into the stomach

(9)

26 Management: variceal bleed

Definitive management • Oesophageal varices: endoscopic variceal band ligation is first line and is superior to sclerotherapy • Gastric varices: endoscopic sclerotherapy with N-butyl-2-cyanoacrylate is first line • Transjugular intrahepatic portosystemic shunt (TIPS): for a variceal bleed (gastric or oesophageal) if endoscopic treatment fails

(10) (11) 27 Prophylaxis: variceal bleed

Beta-blocker • All patients should be commenced on a non-selective beta-blocker • Long-term secondary prevention to reduce rebleeding and mortality

Endoscopic variceal band ligation (EVL): • Used as primary prevention for people with cirrhosis who have medium to large oesophageal varices. • Performed at two-weekly intervals until all varices are eradicated, alongside a PPI to prevent EVL- induced ulceration

28 Rockall score

• Performed post-endoscopy • Factors included: • Age • Shock (blood pressure and heart rate) • Co-morbidities • Endoscopic findings (diagnosis and major stigmata of recent haemorrhage)

29 Management: oesophageal rupture

Considered a surgical emergency • May be performed laparoscopically • Precise approach depends on location

General surgical principles according to WSES guidelines: 1. Excellent exposure 2. Debridement of non-viable tissue 3. Closure of defect 4. Buttress to reinforce oesophageal sutures 5. Adequate tube drainage

A minority of patients may be managed non-surgically e.g. absent features of sepsis, meets specific radiological criteria and close monitoring is possible

30 Management: overview

© BiteMedicine (2020) 31 Complications

System Complication

Cardiovascular • Shock and death

Respiratory Particularly due to Boerhaave syndrome • Acute respiratory distress syndrome • Pneumothorax • Pleural effusion • Chest sepsis

Haematological • Anaemia

Complications of • Endoscopy: perforation, bleeding, infection treatment

32 Top-decile question: 1

33 Top-decile question: 2

34 Top-decile question: leaderboard

35 Recap

• Diagram

36 References

1. Lozzaaa / Public domain 2. https://commons.wikimedia.org/wiki/File:Gastric_Ulcer.png, BruceBlaus / CC BY-SA (https://creativecommons.org/licenses/by- sa/4.0) 3. https://www.shutterstock.com/image-vector/esophageal-varices-128827513 4. Clinical_Cases. Licensed under Creative Commons license. / CC BY-SA (https://creativecommons.org/licenses/by-sa/2.5). https://commons.wikimedia.org/wiki/File:Pneumoperitoneum_modification.jpg 5. Jto410 / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:CXR_Pneumomediastinum.jpg 6. Jto410 / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:Boorhaave1.JPG 7. Jto410 / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0). https://commons.wikimedia.org/wiki/File:BoorhaaveSag_CT.JPG 8. Ed Uthman, MD / Public domain 9. Olek Remesz (wiki-pl: Orem, commons: Orem) / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 10. Samir / Public domain 11. R. Torrance Andrews, MD / CC BY (https://creativecommons.org/licenses/by/1.0) All other diagrams and flowcharts are copyrighted and owned by © BiteMedicine (2020). These images/figures may not be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without prior written permission of BiteMedicine, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For permission requests, please email us at [email protected]

37 Further information

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