Upper Gastrointestinal Haemorrhage

Context

Upper gastrointestinal (GI) haemorrhage is a common presentation to the emergency department, and accounts for approximately 50-70,000 admissions per year.

The overall incidence of acute upper GI bleeding in the UK ranges from 84-172 per 100,000 of the population per year. Incidence is highest in the elderly, and lower socioeconomic groups.

Despite changes in medical management, mortality has remained at around 10% for the last fifty years. [1]

Definition

An upper GI haemorrhage can be defined as any bleeding which occurs from a source proximal to the ligament of Treitz [2]. This is the suspensory ligament of the duodenum that marks the duodenojejunal junction.

Common causes of upper GI bleeding in the UK are shown in the chart above.

Peptic ulcer disease is the most common cause of upper GI bleeding, accounting for just over half of its hospital admissions. [3]

In peptic ulcer disease, haemorrhage occurs from erosion to a blood vessel at the ulcer base.

In patients with liver disease, increased portal venous pressure results in greater blood flow through collateral vessels (particularly in the distal oesophagus). These vessels can become dilated and tortuous, making them prone to bleeding.

The anatomical locations of the causes of upper GI bleeds are shown in the image below

Blood transfusion decision should be based on the full clinical picture. It should be noted that over-transfusion has complications, and that studies have shown a reduction in mortality when transfusion is restricted to patients with a haemoglobin less than 7g/dL (less than 9g/dL in unstable coronary artery disease).

Platelet transfusion should only be offered to patients with a platelet count less than 50 x 10⁹/litre who are actively bleeding.

Fresh frozen plasma (FFP) should be used in actively bleeding patients with a prothrombin time (PT), INR, or activated partial thromboplastin time (aPTT) greater than 1.5 times the normal upper limit. Cryoprecipitate can be used in patients with a fibrinogen that remains less than 1.5g/L despite using FFP.

For patients taking warfarin who are actively bleeding, offer prothrombin complex concentrate (PCC). If bleeding has stopped, follow local warfarin protocols.

Thromboelastography can also be used if readily available to guide transfusion of clotting products.

Learning Bite:

Patients with melena tend to present with lower haemoglobin values than those with haematemesis (most likely due to presentation being slightly later with melena)

In patients who are critically unwell, resuscitation is warranted. Signs of haemodynamic instability should be looked for, such as tachycardia (though the elderly, or those on beta-blockers may not mount this response), widened pulse pressure, tachypnoea, or hypotension.

Involve senior emergency medicine colleagues early and begin resuscitation using an ABC approach.

• High concentration oxygen via non-rebreather mask
• Large bore peripheral IV access consider intraosseous if access is difficult
• Transfusion according to local protocols, consider activation of the major haemorrhage pathway
• Urinary catheter to measure output
• Urgent referral to your endoscopy service know your local policy!
• Consider involving the critical care team particularly if haemodynamic instability persists despite adequate resuscitation.

Variceal Bleed

Variceal bleeds are uncommon, even in patients with a known alcohol related liver disease. Mortality is high and up to 30% of patients with known varices are likely to re-bleed. [6]

A variceal bleed is suggested by evidence of decompensated liver disease, such as jaundice, ascites or encephalopathy.

Known or suspected variceal bleeds should always be considered high risk as, in hospital, mortality is approximately 50%. [7]

All patients should be referred for urgent endoscopy and should undergo a critical care review to determine need for admission to a high dependency area.

Glasgow-Blatchford Score

The Glasgow-Blatchford Score (GBS table 1) is the risk assessment tool of choice in the emergency department. [8]

It is calculated using 4 components medical history (hepatic disease, heart failure), symptoms (melaena, syncope), signs (tachycardia, blood pressure), and blood tests (haemoglobin, urea).

An online score calculator is ideal to use as individual components can have values between 0 and 6. The maximum score is 29.

NICE recommends that patients with a GBS of 0 can be considered for early discharge with outpatient endoscopy follow up. [1]

The British Society of Gastroenterology consensus statement extends this to patients with a GBS of 0 or 1. [9]

Table 1 The Glasgow-Blatchford Score

Rockall Score

Clinical diagnosis is largely based on the patients history however investigations are useful to risk assess (by enabling calculation of risk stratification scores) and guide management.

These investigations could include:

• Full blood count
• Urea and electrolytes (a urea raised out of proportion to the creatinine can suggest a significant volume GI bleed)
• Liver function tests (to identify underlying liver disease)
• Coagulation screen
• Cross match
• Venous blood gas might help with a quick measure of the haemoglobin, but this is unreliable in active bleeding
• Imaging CT abdomen with contrast may be useful as interventional radiology may be a viable management option if endoscopy fails.

Non-variceal Bleeds

Proton Pump Inhibitors (PPIs)

PPIs such as omeprazole are widely used. Theoretically they reduce bleeding by increasing the pH of the normally acidic gastric environment, leading to clot stability.

Post-endoscopy they have been shown to reduce the rebleeding rate and need for surgery but have no effect on overall mortality. [11]

Evidence for their use before endoscopy is conflicting. A Cochrane review found treatment probably reduced the need for endoscopic treatment of bleeding but had no effect on mortality or other outcomes. [12]

NICE advise that PPI therapy should not be given pre-endoscopy. [1]

Learning Bite

Whilst PPIs are commonly used in the management of upper GI bleeds, there is little evidence to support their use in the emergency department.

Antifibrinolytic Therapy

The HALT-IT trial was published in 2020 and looked at the effectives of high-dose 24-hour infusion of tranexamic acid (TXA) in patients with acute HI bleeding. 12,009 patients were randomised to TXA or placebo. They found no difference between the groups in the primary outcome of death from bleeding within 5 days, and no significant differences in any of the secondary outcomes, other than an increase in venous thromboembolic events in the TXA group. [13]

Its important to remember though that only patients where the treating clinician was uncertain as to the benefits of TXA were enrolled, and so TXA could still be considered in patients with massive haemorrhage in line with local practice.

Variceal Bleeds

Endoscopy

Endoscopy is the gold standard for diagnosing and treating an upper GI haemorrhage. The timing of endoscopy is important and should take place only after the patient is adequately resuscitated. Common therapies include injection or thermal therapy for a bleeding peptic ulcer, or banding of oesophageal varices.

Endoscopy controls bleeding initially in around 90% of patients with bleeding peptic ulcers. [16] Mallory-Weiss tears normally stop without endoscopic intervention.

Patients should be clinically assessed and risk stratified using scoring systems to help determine how urgently endoscopy should be performed and to what level of care facility they should be admitted.

Learning Bite

High-risk bleeds need urgent endoscopy, both for diagnosis and therapy.

Interventional Radiology

If endoscopy is unsuccessful or contraindicated, or if bleeding persists despite medical and endoscopic treatment, interventional radiology could be considered depending on local availability.

CT angiogram can often identify the aetiology of GI bleeding which can provide important information for intervention. Culprit vessels for upper GI bleeding include branches of the coeliac axis, such as the left gastric artery, and the gastroduodenal artery.

Once the source is identified, transcatheter arterial embolisation can be used to occlude the culprit vessel as close as possible to the bleeding site. Embolic agents used include coils, glue, polyvinyl alcohol particles, and Amplatzer vascular plugs. [17]

Balloon Tamponade

Balloon tamponade devices, such as the Sengstaken-Blakemore tube (3 lumen) or Minnesota tube (4 lumen due to inclusion of an oesophageal aspiration port), should be inserted in patients with variceal haemorrhage that has continued to bleed despite medical therapy when endoscopy is not immediately available. These devices are only temporary measures pending definitive management by endoscopy.

Tamponade provides good control of bleeding in 90%, although most will re-bleed within 24 hours. [7]

Balloon Tamponade Procedure

1. Ideally secure the patients airway with endotracheal intubation
2. Ensure the tube is intact, check both gastric and oesophageal balloons by inflating each with 50ml or air and deflate both fully
3. Spigot the aspiration ports
4. Lubricate the tube
5. Insert the tube to at least 50cm via the mouth and remove the guidewire. If the guidewire cannot be removed easily pull the tube back to 45cm and try again, if unsuccessful then remove the tube and reinsert
6. Inflate the gastric balloon in 50-100ml increments up to the maximally recommended volume (250-400ml depending on the tube). Do not routinely inflate the oesophageal balloon
7. Pull back on the tube and secure with a rope-and-pulley system with a 500ml bag of fluid for weight, or to the mouth with a tongue depressor and padding system
8. Arrange an urgent portable chest XR to confirm the position
9. The oesophageal balloon should only be inflated if bleeding continues (inflate to 40mmHg)

Balloon Tamponade Complications

Complications include:

• Oesophageal necrosis and perforation from inflation of the oesophageal balloon, or the gastric balloon in an incorrect position
• Aspiration if the airway is not secured first
• Mucosal ulceration from pressure (do not leave in situ for more than 24-36 hours, and periodically deflate and reinflate)
• Proximal migration of the tube causing airway obstruction
• Ongoing haemorrhage from incorrect insertion or position

Further treatment options if endoscopy fails include surgery, angiography and embolisation, or TIPSS. Transjugular Intrahepatic Porto-Systemic Shunt is a radiological intervention in which a connection is made between the portal and hepatic venous systems to reduce portal venous pressure. This procedure may be performed in patients with varices who continue to bleed despite other therapies.

Learning Bite

Balloon tamponade is an effective method of controlling a variceal haemorrhage until definitive intervention.

In assessing the patient with an upper GI bleed there are several pitfalls. The most important of these is failing to recognise those patients that require prompt resuscitation, urgent endoscopy and admission to a critical care area (haemodynamic abnormalities or a Rockall score of three or more).

It is vital, in a shocked patient with no apparent cause, to perform a rectal exam early to avoid missing melaena. Be aware of the patient with an unexplained postural hypotension or syncope and assess for an unrecognised GI haemorrhage.

In terms of variceal bleeds: consider antibiotics and terlipressin early. If considering a Sengstaken tube, remember to secure the airway prior to its insertion.

1. Acute upper gastrointestinal bleeding in over 16s: management. CG141. Updated August 2016
2. Henneman PL. Gastrointestinal Bleeding. In Rosens Emergency Medicine, 5th 2002 Edition, Mosby, London, pg 195
3. Wuerth BA, Rockey DC. Changing epidemiology of upper gastrointestinal hemorrhage in the last decade: a nationwide analysis. Dig Dis Sci2018;63:1286-93
4. Laine L, Laursen SB, Zakko L, et al., Severity and Outcomes of Upper Gastrointestinal Bleeding With Bloody Vs. Coffee-Grounds Hematemesis. Am J Gastroenterol. 2018 Mar;113(3):358-366.
5. Mellemkjr L, Blot WJ, Srensen HT, et al. Upper gastrointestinal bleeding among users of NSAIDs: a population-based cohort study in Denmark. Br J Clin Pharmacol. 2002 Feb; 53(2): 173181
6. Vreeburg EM, Terwee CB, Snel P, et al. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut 1999;44(3):331-35
7. Jalan R, Hayes PC. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2000;46(3):iii1-iii15
8. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000 Oct 14;356(9238):1318-21.
9. Siau K, Hearnshaw S, Stanley AJ, et al. British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding. Frontline Gastroenterol. 2020 Mar 27;11(4):311-323.
10. Rockall TA, Logan RFA, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38(3):316-21
11. Sreedharan A, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database of Systematic Reviews 2010, Issue 7
12. Kanno T, Yuan Y, Tse F, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2022 Jan 7;1(1):CD005415.
13. Roberts I, Shakur-Still H, Afolabi A, et al., Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 2020; 395(10241):1927-1936.
14. Tripathi D, Stanley AJ, Hayes PC, et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015 Nov;64(11):1680-704.
15. Chavez-Tapia NC, Barrientos-Gutierrez T, et al. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Sep 8;2010(9):CD002907.
16. Palmer K. Non-variceal upper gastrointestinal haemorrhage: Guidelines. Gut 2002;51:1-6.
17. Ramaswamy RS, Choi HW, et al. Role of interventional radiology in the management of acute gastrointestinal bleeding. World J Radiol. 2014 Apr 28;6(4):82-92.