Upper GI Bleeding HH Tsai MD FRCP FECG Consultant Gastroenterologist Financial Disclosures • I have no financial relationship with any manufacturer or supplier of any product mentioned in this talk. GI Audits: • Q: What was the mortality of UGIB in audits carried out in following years: • 1945 • 1994 • 2007 GI Audits: • Q: What was the mortality of UGIB in audits carried out in following years: • 1945 A:11% • 1994 A: 14% • 2007 A: 10% What scoring system best predicts clinical outcome? • Rockall score? (1994) • Batchford Score? (2000) • Another? • My clinical judgement Both poor, but better than nothing • The Blatchford score had 54% accuracy for predicting the need for intervention or death within 30 days. The Rockall score had 53% pre-endoscopy accuracy and 61% accuracy post-endoscopy. Both scores were described as having suboptimum sensitivity and specificity. • Blatchford score had better overall prognostic ability than the pre-endoscopy Rockall score (area under curve [AUC]=0.79 versus 0.62 respectively, p=0.0001). However, the Blatchford score and the post-endoscopy Rockall score had similar prognostic ability (AUC=0.79 versus 0.72 respectively, p=0.26). • Chandra 2014 Case 1 • 70 yr old hypertensive patient on NSAID’s with H&M: Admission P 90 BP 120/90 Hb 7.2 g/dL • Do you transfuse? • What Hb do you aim for? Villanueva 2013 • Single-centre randomised controlled trial (n=921) of liberal versus restrictive blood transfusion strategies in adults admitted with haematemesis or bloody nasogastric aspirate, or melaena. • In the restrictive group, the transfusion threshold was haemoglobin of 7 g/dl with a post-transfusion target of 7–9 g/dl. • In the liberal group, the transfusion threshold was 9 g/dl with a post-transfusion target of 9–11 g/dl. • The primary outcome was death from any cause in the first 45 days Villanueva 2013 NEJM Mortality % 10 9 8 7 6 5 Mortality % 4 3 2 1 0 Restrictive Liberal 921 UGIB pts randomized to trfX thresholds of Hgb<7 or 9gm/dL, stratified by cirrhosis 15% vs 51% trfX rates, P<0.001 95% vs 91%*, OR=0.55, 0.33-0.92 Villanueva, NEJM, 2013 Villanueva, NEJM, 2013 1.1 Risk assessment • 1.1.1 Use the following formal risk assessment scores for all patients with acute upper gastrointestinal bleeding: • the Blatchford score at first assessment, and • the full Rockall score after endoscopy. • 1.1.2 Consider early discharge for patients with a pre-endoscopy Blatchford score of 0. Blood products: • 3. Transfuse patients with massive bleeding with blood, platelets and clotting factors in line with local protocols for managing massive bleeding. • 4. Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion. • 5. Do not offer platelet transfusion to patients who are not actively bleeding and are haemodynamically stable. • 6. Offer platelet transfusion to patients who are actively bleeding and have a platelet count of less than 50 x 109/litre. • 7. Offer fresh frozen plasma to patients who have either • a fibrinogen level of less than 1g/litre or • a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal. • 8. Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding. • 9. Treat patients who are taking warfarin and whose upper gastrointestinal bleeding has stopped in line with local warfarin protocols. • 10. Do not use recombinant factor Vlla except when all other methods have failed. Timing of endoscopy • 11. Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation. • 12. Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding. • 13. Units seeing more than 330 cases a year should offer daily endoscopy lists. Units seeing fewer than 330 cases a year should arrange their service according to local circumstances. Management of non-variceal bleeding • Endoscopic treatment: • 12. Do not use adrenaline as monotherapy for the endoscopic treatment of non-variceal upper gastrointestinal bleeding. • 13. For the endoscopic treatment of non-variceal upper gastrointestinal bleeding, use one of the following: • • a mechanical method (for example, clips) with or without adrenaline • • thermal coagulation with adrenaline • • fibrin or thrombin with adrenaline Proton Pump Inhibitors: • 14. Do not offer acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding. • 15. Offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy. Treatment options after first or failed endoscopic treatment • 16. Consider a repeat endoscopy, with treatment as appropriate, for all patients at high risk of re- bleeding, particularly if there is doubt about adequate haemostasis at the first endoscopy. • 17. Offer a repeat endoscopy to patients who re- bleed with a view to further endoscopic treatment or emergency surgery. • 18. Offer interventional radiology to unstable patients who re-bleed after endoscopic treatment. Refer urgently for surgery if interventional radiology is not promptly available. Management of variceal bleeding • Terlipressin: • 11. Offer terlipressin to patients with suspected variceal bleeding at presentation. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its usea . • Antibiotics: • 19. Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding • Oesophageal varices • 20. Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices. • 21. Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation. • Gastric varices • 22. Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with upper gastrointestinal bleeding from gastric varices • 23. Offer transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate. Control of bleeding and prevention of re-bleeding • 24. Continue low-dose aspirin for secondary prevention of vascular events in patients with upper gastrointestinal bleeding in whom haemostasis has been achieved • 25. Stop other non-steroidal anti-inflammatory drugs (including cyclooxygenase-2 [COX-2] inhibitors) during the acute phase in patients presenting with upper gastrointestinal bleeding. • 26. Discuss the risks and benefits of continuing clopidogrel (or any other thienopyridine antiplatelet agents) in patients with upper gastrointestinal bleeding with the appropriate specialist (for example, a cardiologist or a stroke specialist) and with the patient. Primary prophylaxis • 27. Offer acid-suppression therapy (H2-receptor antagonists or proton pump inhibitors) for primary prevention of upper gastrointestinal bleeding in acutely ill patients admitted to critical care. If possible, use the oral form of the drug. • 28. Review the ongoing need for acid-suppression drugs for primary prevention of upper gastrointestinal bleeding in acutely ill patients when they recover or are discharged from critical care. Information and support for patients and carers • 29. Establish good communication between clinical staff and patients and their family and carers at the time of presentation, throughout their time in hospital and following discharge. This should include: • • giving verbal information that is recorded in medical records • • different members of clinical teams providing consistent information • • providing written information where appropriate • • ensuring patients and their families and carers receive consistent information. Mortality with or without rebleed Initially created to check the need for inpatient or outpatient treatment www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs Resuscitation • Immediate: Venous access and crystaloids/colloids • Transfuse blood if: active severe bleed/exsanguination risk • In stable patients, only if Hb <7 g/dl, target 9 g/dl 921 UGIB pts randomized to trfX thresholds of Hgb<7 or 9gm/dL, stratified by cirrhosis 15% vs 51% trfX rates, P<0.001 95% vs 91%*, OR=0.55, 0.33-0.92 Villanueva, NEJM, 2013 Endoscopy • When? • Where? • How? Upper GI Tract Site • Oesophagus • Stomach • Doudenum • Hepatic • Pancreatic 58 year-old man presented with upper gastrointestinal bleeding – hematemesis and melena The visible vessel", which was bleeding intermittently was successfully eradicated with the heater probe. There was no recurrent bleeding. Predictors of re-bleeding Endoscopic findings Location of the ulcer (post DU, High lesser curve) Age > 60 Shock / anaemia on admission Size of the ulcer Other causes Angiodysplasia • Angiodysplasia, arteriovenous malformations and vascular ectasia are used synonymously • Argon Therapy – Use argon gas to arc current to tissue, allows directed superficial ‘burn’ ~1mm deep – Good for large areas like GAVE or tumors – Very low risk of perforation Mucosal Tear (Mallory – Weiss) Mallory-Weiss tears present in a classic pattern ( Emesis followed by Haematemesis ) 90% of Mallory-Weiss bleeding resolves spontaneously and require no further therapy. If bleeding persists, endoscopic therapy may be required Dieulafoy’s vascular malformations They are dilated