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The Treatment of Haematemesis and Upper Gastrointestinal Bleeding in United Kingdom Armed Forces and Other Deployed Units

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The Treatment of Haematemesis and Upper Gastrointestinal Bleeding in United Kingdom Armed Forces and Other Deployed Units J Royal Naval Medical Service 2014, Vol 100.3 308 The treatment of haematemesis and upper gastrointestinal bleeding in United Kingdom Armed Forces and other deployed units Surg Lt R Arr Woodward, Surg Cdr M Khan Abstract Introduction Upper Gastro-intestinal (UGI) bleeding is a significant cause of morbidity worldwide. United Kingdom Armed Forces (UKAFs) are not immune to this condition. There is a substantial body of conflicting evidence regarding initial management and risk stratification. Aim To provide the background knowledge and treatment pathways required to assess and manage a patient adequately during the first 24 hours of an episode of UGI bleeding. Assessment Clinical grading of hypovolaemic shock is inaccurate, but is a broad indicator of severity; the Rockall Score must not be used to assess requirement for intervention. Where laboratory assets are available, the Blatchford score is adequate to assess requirements for intervention. Management The principles of hypotensive resuscitation (target systolic blood pressure 90 mmHg for the first hour) hold true for UGI bleeds. In areas where endoscopy is available within four hours, a restrictive pattern of packed Red Blood Cell (pRBC) transfusion may be beneficial. Despite limited evidence of benefit, Proton Pump Inhibitors (PPIs) should be given routinely in UKAFs. Where available, in cases of variceal and non-variceal UGI Haemorrhage without locally available endoscopy, administration of tranexamic acid and somatostatin or octreotide should be considered. Introduction however, Role One units, in particular Royal Naval or Upper Gastro-intestinal (UGI) bleeding is one of the most light infantry units, often operate outside of effective common causes of admission to hospital in the United local medical care. In these situations, a good knowledge Kingdom (UK), with an annual incidence of 134/100,000 of initial actions, risk assessment and the evidence base (1). This is more common than acute appendicitis behind further management is essential for Role One (84/100,000 (2)), and with a mortality of approaching 10% medical personnel, as well as those at higher levels of care. it is one of the more significant causes of morbidity in acute settings (1). Specific Challenges for UKAFs UKAFs often operate in austere environments: even at 80% of UGI bleeds are self-limiting (3). The ‘gold standard’ Role Two and Role Three resources are restricted, and the investigation and treatment for all significant UGI bleeds availability of interventions is not guaranteed; this limits is therapeutic Oesophago-Gastro-Duodenoscopy (OGD), the management options available to deployed medical along with fluid and blood product replacement (4). practitioners. United Kingdom Armed Forces (UKAFs) do not deploy with an organic endoscopic capability even at Role Three. Firstly, OGD is not available within operational theatres, so This increases the reliance on local medical facilities; accurate assessment of patients with the aim of identifying 309 Clinical those most at risk is essential. Secondly, blood products (as a high concentration, and to dissolve in and through well as other products and medications mentioned below) the bicarbonate protective layer of the gastric mucosa. are not always carried and are frequently restricted in Once present in the mucosa, the inhibition of COX 1 quantity even if they are. Therefore, the use of these products mediated prostaglandins rapidly reduces the production of should be rational and limited to those patients most likely bicarbonate, thus rendering the gastric mucosa vulnerable to receive maximal benefit. Finally, although focus is often to erosion. There is little evidence that traditional non- on the acute management of bleeding, Role One also acts pharmacological methods of reducing ulcer formation as a primary care facility for deployed personnel. It is worth (e.g. taking NSAIDs with food) leads to any reduction in bearing in mind that most UGI symptoms or bleeding pathology (9). encountered will be of a chronic nature. H. pylori is endemic throughout the world, and the Epidemiology greatest risk factor for transmission is crowded conditions, The risk factors for UGI bleeding (Box 1) (5,6) suggest that often linked to social deprivation (10). Due to the living UKAFs may be in a higher risk category due to the fact conditions associated with military life, it is reasonable to that alcohol abuse, Non Steroidal Anti-Inflammatory Drug anticipate infection rates to rise with military service or (NSAID) use and smoking are all endemic; this is coupled deployment. An observational study showed that deployed with the psychological stress of operations (5,7). There is US Naval personnel showed an increase in prevalence little data available on the incidence of UGI bleeding in UK following a six-month deployment south of the equator, forces. However, an analysis of United States (US) troops but whether this increase resulted from crowding or from suggests that the incidence is lower in military personnel than contact with local populations was not established (11). others (34/100,000 personnel per year) (7). One theory for this is that age is a major risk factor, and this is a protective A rarer cause of UGI bleeding, in particular profuse factor in a predominantly younger military population. haematemesis, is oesophageal varices. These are swollen veins (varicosities) that arise at the cardiac sphincter, due to Despite this apparent protection, there are specific risk venous diversion secondary to portal venous hypertension. factors on operations to be considered. Trauma is a major The most common cause is liver cirrhosis, and in risk for UGI ulceration with an incidence of 25% in trauma forces and ex-forces populations this is predominately patients requiring Intensive Care Unit (ICU) admission secondary to alcohol abuse. However, in local populations, (5). The mechanism can be direct trauma, ischaemia to the schistosomiasis or chronic viral hepatitis should be gastric mucosa (Curling’s ulcer), or associated physiological considered. The treatment of variceal haemorrhage is highly stress in intensive care environments. Mortality amongst specialised and will not be covered in detail here. However, in-patients who develop UGI bleeding is higher (8). For the principles and broad management are discussed and this reason, gastric ulcer prophylaxis for trauma patients is remain the same as for non-variceal haemorrhage. now routine. Other causes include Mallory-Weiss tears (tears in the Risk Factors: mucosal lining of the oesophagus due to prolonged retching) • Alcohol Abuse or oesophagitis, as the result of either prolonged retching • Chronic Renal failure or acid reflux. These can be expected in personnel who • Non-Steroidal Anti-Inflammatory Use (NSAID) through intoxication or gastro-oesophageal reflux disease • Age have exposed the oesophagus to either acid or physical • Lower Socio-Economic Class stress. The most severe complication of this is oesophageal • Smoking perforation, which is suggested by severe retrosternal pain • Stress and also surgical emphysema in the throat, or allied chest • Trauma symptoms. Box 1: Risk factors for UGI bleeds. The common causes of UGI bleeding are listed in Table 1(12). Pathophysiology The most common causes of UGI bleeding and Assessment haematemesis are gastroduodenal erosions and ulceration. As seen in Table 2, significant UGI bleeding rarely presents Erosions in the gastric mucosa are predominately caused with haematemesis in isolation. However, it needs to be by NSAID use or infection by Helicobacter pylori. Non- noted that bright red vomitus (true haematemesis) is a specific Cyclooxygenase (COX)1 and COX 2 inhibitors reliable sign of ongoing UGI bleeding and needs to be dealt (NSAIDs) are weakly acidic and so disassociate freely in with as an emergency. Regardless of the underlying cause the acidic stomach environment, enabling them to retain the initial approach depends on the haemodynamic state of J Royal Naval Medical Service 2014, Vol 100.3 310 Cause Features Gastric Ulcer Epigastric / right upper quadrant pain Duodenal Ulcer Melaena Gastritis Coffee ground vomit Erosive Duodenitis Frank haematemesis History of NSAID use Epigastric pain / indigestion. Mallory-Weiss tear Retching Emesis (without blood initially) Coughing Fresh blood streaks in otherwise normal vomitus No melaena or coffee ground vomit Oesophagitis Reflux Oesophageal Ulcer Dysphagia Nocturnal cough Malignancy Dysphagia Early satiety Weight loss Oesophageal Varices Jaundice Portal Hypertensive Gastropathy Ascites Caput medusa Signs of chronic liver disease Profuse bleeding Table 1: Causes and features of UGI bleeding. the patient, and a rapid assessment needs to be made. Table young, fit patients (14), especially in active, healthy Armed 2 outlines the basic clinical markers that should be assessed Forces personnel who frequently have resting heart rates (12,13,14). Following assessment, a decision can be made below 60 beats per minute. as to whether urgent volume resuscitation and intervention is required, or if less urgent investigation is appropriate. The gold standard for diagnosis is OGD, as direct Deficit 0-15% 15-30% 30-40% 40% Pulse 60-90 90-120 >120 >120 Blood Pressure Normal Postural Drop sBP Decreased sBP <90 Pulse Pressure by ~ 30-40 <30 mmHg mmHg Capillary Refill <2 Seconds > 2 Seconds > 3 Seconds > 3 Seconds Respiratory Rate 12-16 16-20 >20 >30 *sBP = Systolic Blood Pressure Table 2: Signs of haemodynamic compromise and the corresponding
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