4 Postgrad Med J: first published as 10.1136/pmj.78.915.4 on 1 January 2002. Downloaded from REVIEW Management of gastrointestinal haemorrhage S Ghosh, D Watts, M Kinnear ............................................................................................................................. Postgrad Med J 2002;78:4–14 A variety of endoscopic haemostatic techniques have RESUSCITATION enabled major advances in the management of not only In any patient with a significant gastrointestinal haemorrhage, history taking, physical examina- bleeding peptic ulcers and bleeding varices, but also in tion, and resuscitation need to proceed simulta- a variety of bleeding lesions in the small intestine and in neously. An immediate assessment of haemody- the colon. Indeed, the development and widespread namic status and red cell transfusion requirements must be made, including vital signs implementation of endoscopic haemostasis has been in the supine, sitting and, where appropriate, in one of the most important developments in clinical the standing position. Hypotensive patients re- gastroenterology in the past two decades. An quire to be placed in a head-down position to aid cerebral perfusion. The supine position should increasingly ageing cohort of patients with multiple generally be avoided while resuscitating, as this co-morbidity are being treated and therefore improving risks pulmonary aspiration. Supplemental oxy- the outcome of gastrointestinal bleeding continues to gen may help a confused, agitated elderly patient with poor cerebral perfusion. Central venous pose major challenges. pressure (CVP) monitoring is desirable in patients .......................................................................... with organ failure requiring blood transfusion or those with profound shock. CVP monitoring is astrointestinal haemorrhage is one of the especially valuable in monitoring elderly patients with severe cardiovascular disease, and guides most common medical emergencies. All fluid replacement. An unexpected drop in CVP medical and general surgical units need to G may also indicate rebleeding. A full blood count, be familiar with the efficient management of blood urea and creatinine, prothrombin time, gastrointestinal haemorrhage, and close collabo- activated partial thromboplastin time, type, and ration between medical and surgical teams is cross match should be obtained in all patients essential. There is some evidence that manage- urgently. In haemodynamically compromised ment is best undertaken in a specialised area patients intravenous infusion of normal saline according to agreed protocols and guidelines. A should be started while red cells are being cross http://pmj.bmj.com/ multidisciplinary clinical care pathway may im- matched. The crystalloid versus colloid contro- prove the efficiency of care for patients with acute versy continues and methodological limitations upper or lower gastrointestinal haemorrhage.1 In of the trials preclude any definite evidence based addition, trained endoscopy assistants, interven- clinical recommendation. Given the lack of tional radiologists, and intensivists are all impor- evidence in favour of colloids, crystalloids are the tant team members in managing patients with convenient and inexpensive choice for fluid severe haemorrhage. resuscitation. The evidence to guide red cell In this article, the management of gastro- transfusion is limited. A randomised study found on September 27, 2021 by guest. Protected copyright. intestinal haemorrhage is discussed with special more rebleeding in patients transfused early, but 3 emphasis on the site of haemorrhage and the this study is small. Patients with sustained brisk underlying diagnosis. The diagnostic approach as bleeding should of course be transfused urgently well as therapeutic intervention depends on the to prevent catastrophic exsanguination. If the site of haemorrhage, the rapidity of blood loss, haemoglobin concentration is less than 100 g/l in a patient with postural hypotension, it may be and the nature of the bleeding lesion. A prelimi- sensible to transfuse, as the haemoglobin will nary clue to the site of haemorrhage is the continue to drift downwards after crystalloid presence of haematemesis and increase of blood infusion. Patients with cardiovascular disease and urea nitrogen (upper gastrointestinal), or the symptoms such as angina should be transfused to presence of rectal bleeding (colonic). It has been maintain a haemoglobin above 100 g/l. In all other suggested that a pocket gastrointestinal colour situations, blood transfusion may be safely with- confirmation card to corroborate the patient’s held till the haemoglobin is less than 70–80 g/l. See end of article for history may be useful in directing subsequent The issue about coronary artery disease and elec- authors’ affiliations investigations.2 Insertion of nasogastric tube and trocardiography is discussed later. Chest radio- ....................... aspiration may be helpful in localisation of bleed- graphy is optional but a baseline radiograph may Correspondence to: ing and demonstration of rebleeding, but can be help assessment if the patient later develops Dr Subrata Ghosh, misleading. It is poorly tolerated by patients and symptoms suggestive of pulmonary aspiration. Western General Hospital, Edinburgh EH4 2XU, UK; rarely used in UK practice. Though appropriately [email protected] timed surgical intervention is an integral part of ................................................. management of gastrointestinal haemorrhage, Submitted 14 June 2001 Abbreviations: COX-2, cyclo-oxygenase-2; CVP, central Accepted 21 August 2001 details of surgical management are beyond the venous pressure; IDA, iron deficiency anaemia; NSAIDs, ....................... scope of this review. non-steroidal anti-inflammatory drugs www.postgradmedj.com Management of gastrointestinal haemorrhage 5 Postgrad Med J: first published as 10.1136/pmj.78.915.4 on 1 January 2002. Downloaded from Box 1: Causes of acute upper gastrointestinal Box 2: Modified Forrest criteria for peptic ulcer haemorrhage haemorrhage • Peptic ulcer disease. 1. Actively bleeding ulcer. • Oesophageal/gastric varices. • 1a. Spurting. • Haemorrhagic gastritis. • 1b. Oozing. • Oesophagitis. 2. Non-actively bleeding ulcer. • Mallory-Weiss tear. • 2a. Non-bleeding visible vessel. • Cameron ulcers within hiatus hernia. • 2b. Ulcer with surface clot. • Oesophageal, gastric, duodenal neoplasms. • 2c. Ulcer with red or dark blue spots. • Haemobilia. 3. Ulcer with clean base. • Dieulafoy’s lesion. • Aortoenteric fistula. around 5%, whereas if the score equals 8 or more the rebleed- ing rate is over 40%. The mortality rate is below 1% if the risk UPPER GASTROINTESTINAL HAEMORRHAGE score is between 0–2, whereas with a score of 8 or more the This is arbitrarily defined as gastrointestinal haemorrhage mortality may be as high as 41%. from a source proximal to the ligament of Treitz. The presen- Endoscopic findings provide the best estimation of the risk tation may be acute with haematemesis and/or melaena or of rebleeding. Endoscopic stigma of recent haemorrhage (fig chronic with iron deficiency anaemia as discussed later. The 1A and B) are of prognostic value for rebleeding in case of causes of acute upper gastrointestinal haemorrhage to peptic ulcer bleeding. The modified Forrest criteria (box 2) consider at presentation are shown in box 1. Early endoscopy originally devised in Edinburgh in 1974 is widely used,5 permits accurate risk stratification. Morbidity and mortality though even experts can differ in interpretation.6 are higher in those with rebleeding and 95% of rebleeding In the presence of shock, an actively bleeding peptic ulcer occurs within the first 72 hours of hospitalisation. carries an 80% risk of further bleeding in hospital. The presence of a non-bleeding visible vessel carries a 50% risk of Risk stratification further bleeding. The visible vessel represents a pseudoaneu- The risk of death after admission to hospital for acute gastro- rysm of the involved artery, or an adherent blood clot (fig 1B). intestinal bleeding depends on age, the presence of shock, Patients with an adherent blood clot over an ulcer base are also co-morbid conditions, presence of major stigma of recent at considerable risk of further haemorrhage in hospital. haemorrhage, and the underlying diagnosis. Based on host Patients with a clean ulcer base or who have black, blue, or red factors, patient course, and endoscopic features a number of spots rarely rebleed in hospital. Blood flow as measured by clinical scoring systems have been devised as predictors of Doppler ultrasonography via an endoscope can disagree with mortality and rebleeding. Rockall et al have incorporated these endoscopic assessment of stigma of recent haemorrhage. A independent factors into a risk scoring system presented in high false negative and false positive rate for Doppler signals table 1.4 The risk of rebleeding if Rockall risk score equals 0 is have been demonstrated.7 Table 1 The Rockall risk scoring system4 http://pmj.bmj.com/ Score Variable 0123 Age (years) <60 60–79 >80 Systolic blood pressure (mm Hg) >100 >100 <100 Pulse (beats/min) <100 >100 Co-morbidity Nil Cardiac failure, IHD, other major Renal failure, liver failure, comorbidity disseminated malignancy Diagnosis Mallory-Weiss tear, no SRH, All other diagnosis Malignancy upper on September 27, 2021 by guest. Protected copyright. no lesion gastrointestinal tract Stigma of recent haemorrhage None or dark spot Blood in upper