GGC Medicines


Adult Therapeutics Handbook

Management of Upper Gastrointestinal (GI) Haemorrhage

Management of Upper Gastrointestinal (GI) Haemorrhage

Introduction

Assessment

  • Assess pulse and BP (including postural blood pressure if not hypotensive).
  • Check for evidence of significant blood loss, including rectal examination for melaena. If melaena is present it implies that there has been significant blood loss.
  • Check FBC, U&Es and LFTs.
  • Check coagulation if suspected liver disease or on anticoagulation.
  • Assess co-morbidity.
  • Check medication – NSAIDs (non-steroidal anti-inflammatory drugs), aspirin, anticoagulants.
  • Scoring systems can be used to assess risk in these patients and local protocols for individual hospitals exist, dependent on resources and endoscopy services. The Rockall score is the most commonly used endoscopy-based risk score and the Glasgow Blatchford Score (GBS) is the best early (pre-endoscopic) risk score. However, if a patient is haemodynamically unstable with ongoing bleeding, they should be discussed with the on-call surgical team / endoscopist. Other patients should be endoscoped on the next available list.
  • Outpatient management – If the patient's parameters and clinical status fulfil all of the criteria in table 1 (GBS=0) below, then patient can be discharged and managed in outpatient setting. N.B. Patients with GBS <2 could be considered for discharge with urgent outpatient endoscopy.

Table 1 – Criteria for outpatient management (GBS=0)

Parameter Value
Urea <6.5mmol/L
Hb

>130g/L (men)

>120g/L (women)

Systolic BP ≥110mmHg
Pulse <100bpm
Clinical Status
Absence of melaena, syncope, cardiac failure or hepatic disease
GBS – The Lancet, 356 (Iss 9238), Blatchford O, Murray WR, Blatchford M. Risk score for treatment of upper-gastrointestinal haemorrhage, page 1318-21. Copyright (2013), adapted with permission from Elsevier.

General management

All patients:

  • Group and save or crossmatch as clinically indicated
  • Stop NSAIDs, aspirin and anticoagulants
  • Consider reversing anticoagulation (depends on severity of bleeding and indication for anticoagulation, see guideline on Reversal of Anticoagulant Therapy).
  • Repeat Hb as clinically indicated

Patients with haemodynamic compromise and/or significant comorbidities have higher mortality, particularly if elderly. In these patients:

  • Crossmatch 4 units
  • IV access x 2 – use green (18G) needle or larger
  • Consider HDU
  • Resuscitate aggressively. Use blood volume expanders or sodium chloride 0.9% to keep pulse <100bpm, systolic BP >100mmHg, urine output >30ml/hour. Tranfusion to the threshold of 70-80g/L (7-8g/dL) is recommended in most patients but individual comorbidities (e.g. ischaemic heart disease) should be taken into account.
  • If resuscitation difficult consider CVP monitoring.

Contact senior support to decide on timing of urgent endoscopy.

Endoscopy

  • Fast for 3 hours
  • Consent
  • Venflon in situ
  • Ensure case notes and observation charts go with patient.

Post endoscopy

  • If no abnormality found and no drop in haemoglobin: There is a low risk of re-bleeding, consider patient for early discharge.
  • If peptic ulcer disease is found:
    1. Stop NSAIDs, aspirin, clopidogrel or anticoagulants in an acute bleeding situation and reassess the risk versus benefit of reintroduction once the bleeding is controlled. For NSAIDs and antiplatelets use low dose monotherapy if possible and if required concomitant proton pump inhibitor (PPI):

      Lansoprazole oral 30mg each day or omeprazole oral 20mg each day

      If patient is on dual antiplatelet therapy for coronary stents, discuss the risks with the interventional cardiologist. Continuing with a single antiplatelet agent with PPI may be appropriate until repeat endoscopy.

    2. Arrange 13C Urea Breath Test:
      • If positive for H. pylori – see eradication regimen here.
      • If negative for H. pylori and not on NSAIDs – maintain on lifelong PPI (see above for choice and dose).
        • If re-bleeding occurs (fresh melaena or haematemesis associated with a drop in Hb of 20g/L) – seek senior help, including surgical review.
        • If varices, refer to separate guideline here
        • Give specific treatment for other pathologies as indicated.
        • Discuss with gastroenterologist as required.
    3. If stigmata for high risk of re-bleeding (e.g. active bleeding at endoscopy or visible vessel) then the endoscopist may recommend omeprazole IV infusion (Hong Kong Protocol) – dose and administration details here. This is an unlicensed use and so should only be prescribed at the request of a consultant.
      These patients should remain in hospital for 96 hours to monitor for re-bleeding. After infusion initiate PPI oral therapy (see above for choice and dose). The duration of maintenance therapy is variable as dependent on a number of factors. See GGC PPI Guideline on StaffNet, Clinical Guideline Electronic Resource Directory, for guidance.

On discharge

  • Arrange 13C Urea Breath Test in 8 weeks if H. pylori eradication therapy given.
  • Continue PPI for 6 weeks and then change to H2 antagonist prior to breath test.
  • Repeat OGD (Oesophagogastroduodenoscopy) in 8 weeks if gastric ulcer found.