Gastroenterology & Hepatology
This was previously featured in an exam
This was previously featured in an exam
Question 44 of 180
A 51 year old man with a history of hepatitis C cirrhosis is brought into ED with massive haematemesis. Which of the following has been shown to improve survival in a patient with upper GI bleeding?
Answer:
Evidence of pharmacotherapy in upper GI bleeding (UGIB):- Terlipressin
- The two major classes of drugs that have been used in the control of acute variceal bleeding are vasopressin or its analogues and somatostatin or its analogues. Terlipressin is a synthetic analogue of vasopressin, which has an immediate systemic vasoconstrictor action followed by portal haemodynamic effects, reducing portal blood flow, hence variceal bleeding. Terlipressin is the only vasoactive agent that has been shown to reduce mortality in placebo-controlled trials. It should be given to patients with suspected variceal bleeding during resuscitation measures and prior to endoscopic confirmation. N.B. In a recent RCT, somatostatin and its metabolite octreotide have proven to be as effective as terlipressin.
- Proton pump inhibitor
- PPI use prior to endoscopy in UGIB was evaluated in a Cochrane systematic review. It found that PPI significantly reduced the need for endoscopic therapy and reduced the stigmata of recent haemorrhage during index endoscopy, but there was no evidence of improved clinically important outcomes, namely mortality, re-bleeding or need for surgery. NICE therefore advises against the use of PPI prior to endoscopy. PPIs should be prescribed post-endoscopy for those with non-variceal UGIB and stigmata of recent haemorrhage.
- Antibiotics
- I.V. erythromycin as a prokinetic administered prior to endoscopy vs no erythromycin was evaluated in a systematic review. Erythromycin was associated with a greater chance of adequate visualisation of the gastric mucosa, less need for second endoscopy, less blood transfusion and shorter hospital stay. Due to limitations in the studies, an update to NICE, did not recommend erythromycin use as standard.
- Antibiotics that provide Gram-negative cover, such as third generation cephalosporins are one of the interventions which positively influence survival in variceal haemorrhage as shown in a Cochrane meta-analysis. Antibiotics were also shown to reduce bacterial infections and early rebleeding. Therefore, short-term antibiotics should be considered standard practice in all cirrhotic patients who have a variceal bleed, irrespective of the presence of confirmed infection. Antibiotic choice is dictated by local resistance patterns and availability.
- Tranexamic acid
- Tranexamic acid is not currently recommended by NICE for acute UGIB. Further studies are needed to look for benefit in variceal bleeding.
- Adrenaline
- Adrenaline should not be used as a monotherapy for the endoscopic treatment of non-variceal upper gastrointestinal bleeding.
- 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
- Adrenaline should not be used as a monotherapy for the endoscopic treatment of non-variceal upper gastrointestinal bleeding.
Upper Gastrointestinal Bleed
Gastroenterology & Hepatology
Last Updated: 2nd February 2023
Upper gastrointestinal bleeding (UGIB) refers to gastrointestinal blood loss whose origin is proximal to the ligament of Treitz at the duodenojejunal junction. Acute UGIB can manifest in a variety of ways, with or without haemodynamic compromise, including haematemesis, coffee-ground emesis, the return of bright red blood through a nasogastric tube, and melaena. Haematochezia (bright red blood per rectum) may rarely occur in patients with an extremely brisk UGIB.
Causes
The most frequently encountered aetiologies of UGIB are:
- Peptic ulcer disease (26%)
- Gastritis/erosions (16%)
- Oesophagitis (17%)
- No cause found (12%)
- Erosive duodenitis (9%)
- Varices - oesophageal or gastric (8%) - highest mortality
- Portal hypertensive gastropathy (4%)
- Mallory-Weiss tears (3%)
- Malignancy (3%)
- Vascular ectasia (2%)
Risk assessment
Use the following formal risk assessment scores for all patients with acute upper gastrointestinal bleeding:
- the Glasgow Blatchford score at first assessment, and
- the full Rockall score after endoscopy.
The Glasgow-Blatchford Bleeding Score (GBS) helps identify which patients with upper GI bleeding (UGIB) may be safely discharged from the emergency room. Any of the 9 variables, if present, increase the priority for admission (and likelihood of need for acute intervention). Consider early discharge for patients with a pre-endoscopy Blatchford score of 0:
- Blood urea (mmol/L)
- <6.5 =0 points
- 6·5-7·9 = 2 points
- 8·0-9·9 = 3 points
- 10·0-25·0 = 4 points
- >25·0 = 6 points
- Haemoglobin for men (g/L)
- >130 =0 points
- 120-129 =1 point
- 100-119 = 3 points
- <100 = 6 points
- Haemoglobin for women (g/L)
- >120 =0 points
- 100-119 =1 point
- <100 = 6 points
- Systolic blood pressure (mm Hg)
- >110 =0 points
- 100-109 =1 point
- 90-99 =2 points
- <90 =3 points
- Other markers
- pulse ≥100/min =1 point
- presentation with melaena = 1 point
- presentation with syncope = 2 points
- hepatic disease present = 2 points
- cardiac failure present =2 points
The complete Rockall Score estimates mortality in patients with active upper GI bleed who have had endoscopy. The complete Rockall Score is calculated based on clinical bleeding AND endoscopy results. A score of less than 3 carries a good prognosis, but a total score of 8 or higher carries a high risk of mortality:
- Age
- < 60 (0 points)
- 60 – 79 (1 point)
- ≥ 80 (2 points)
- Shock
- No shock – HR < 100 and SBP ≥ 100 (0 points)
- Tachycardia – HR ≥ 100 and SBP ≥ 100 (1 point)
- Hypotension – SBP < 100 (2 points)
- Comorbidities
- Nil major (0 points)
- Any comorbidity EXCEPT renal failure, liver failure, and/or disseminated malignancy (2 points)
- Renal failure, liver failure, and/or disseminated malignancy (3 points)
- Diagnosis on endoscopy
- No lesion and no stigmata of recent haemorrhage (0 points)
- Mallory-Weiss tear (0 points)
- All other diagnoses (1 point)
- Upper GI malignancy (2 points)
- Evidence of bleeding on endoscopy
- No evidence of recent bleeding or dark spot only (0 points)
- Blood in upper GI tract, adherent clot or visible/spurting vessel (2 points)
Management
Acute upper gastrointestinal bleeding (AUGIB) is common and has a case fatality of around 10%. Some 35% of bleeds are caused by peptic ulcer disease but the most severe haemorrhage and highest mortality is seen in the 10% of cases presenting with bleeding from oesophageal or gastric varices.
- Resuscitation and initial management:
- Transfuse patients with massive bleeding with blood, platelets and clotting factors in line with local protocols for managing massive bleeding. Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion (increases risk of rebleeding probably by increasing portal venous pressure).
- Coagulation
- Do not offer platelet transfusion to patients who are not actively bleeding and are haemodynamically stable. Offer platelet transfusion to patients who are actively bleeding and have a platelet count of less than 50 x 10⁹/litre.
- Offer fresh frozen plasma to patients who are actively bleeding and have a prothrombin time (or international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal.
- If a patient's fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma use, offer cryoprecipitate as well.
- Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding. Treat patients who are taking warfarin and whose upper gastrointestinal bleeding has stopped in line with local warfarin protocols.
- Timing of endoscopy:
- Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation.
- Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding.
- Management of non-variceal bleeding:
- Do not use adrenaline as monotherapy for the endoscopic treatment of non-variceal upper gastrointestinal bleeding.
- 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.
- Do not offer acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding.
- Offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy.
- 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.
- Offer a repeat endoscopy to patients who re-bleed with a view to further endoscopic treatment or emergency surgery.
- 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:
- 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 use.
- Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.
- Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices. Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.
- Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with upper gastrointestinal bleeding from gastric varices. Offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate.
- Life-threatening bleeding may be controlled with a Sengstaken-Blakemore tube or a Linton-Nachlas tube until haemostasis can be achieved endoscopically, or with TIPS.
- Control of bleeding and prevention of re-bleeding in patients on NSAIDs, aspirin or clopidogrel:
- Continue low-dose aspirin for secondary prevention of vascular events in patients with upper gastrointestinal bleeding in whom haemostasis has been achieved.
- Stop other non-steroidal anti-inflammatory drugs (including cyclooxygenase-2 [COX-2] inhibitors) during the acute phase in patients presenting with upper gastrointestinal bleeding.
- 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.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
