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 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 • Peptic ulcer disease (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 Portal hypertension • Liver 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 hernia pressure across the gastro- Mallory-Weiss tear • Most diseases that induce oesophageal junction vomiting • 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 • Shock: e.g tachycardia and hypotension • Abdominal pain: e.g. epigastric • Chronic liver disease: pain in peptic ulcer rupture suggests variceal bleed • Encephalopathy • Scleral icterus • Hepatosplenomegaly • 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 • Alcoholic liver disease or other cause of cirrhosis • GORD • ’Heartburn’ • Bloods Oesophagitis • Nausea and bloating • 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 • Pneumoperitoneum: 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).