BMJ Learning

Acute gastrointestinal haemorrhage

د. حسين محمد جمعة
اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2010

Learning outcomes

After completing this module you should know:
How to assess whether patients are at low or high risk of re-bleeding or dying
The role of endoscopy in management
What drugs to start patients on
How to prevent people from having recurrent bleeds.
About the author
Kel Palmer is a consultant gastroenterologist at the Western General Hospital, Edinburgh. He has a particular interest in therapeutic endoscopy and has written extensively about the management of acute gastrointestinal bleeding.
Why I wrote this module
"Acute gastrointestinal haemorrhage is a major medical emergency. It is a condition with high mortality and, although some deaths (for example in patients with multiple medical comorbidities) are inevitable, you can save lives with appropriate resuscitation, endoscopic therapy, surgical intervention, and use of drugs."


Acute gastrointestinal bleeding is a common medical emergency and is responsible for the admission to hospital of 50-170 per 100 000 of the population each year.
A large UK wide audit of acute upper gastrointestinal haemorrhage revealed a hospital mortality of 7% in patients admitted to hospital because of gastrointestinal haemorrhage, rising to 26% in patients who sustained acute gastrointestinal bleeding during the course of admission to hospital for other reasons.

Peptic ulcer

Peptic ulcer is responsible for 35% of cases of haematemesis and melaena. Many patients have no preceding history of dyspepsia.
Oesophageal varices
Oesophageal varices account for 11% of cases of acute gastrointestinal bleeding. This is nevertheless an important subgroup of patients. So you should seek clinical and laboratory evidence of liver disease.

Aorta-duodenal fistula

Aorta-duodenal fistulas usually occur only in patients with a previous history of aortic graft insertion.
Excessive anticoagulation by warfarin
Although anticoagulants might increase the severity of haemorrhage they are not in themselves a cause of bleeding.

Endoscopy with a view to defining the cause of bleeding

Endoscopy should be done only after appropriate resuscitation.
The procedure has significant risks and these are highest in patients who have not been adequately resuscitated.

The initial step is to correct circulatory losses. A meta-analysis has shown that this is best done using intravenous crystalloids. Subsequently, blood transfusion is clearly necessary in this patient.
Patients who have multiple medical problems are best managed in the a high dependency unit HDU.

Central venous pressure monitoring is particularly useful for patients who have evidence of significant cardiac disease because it helps guide fluid replacement.
The coagulopathy should be corrected using clotting factors.


Table 1. The Rockall risk assessment score

Variable

Score

0
1
2
3
Age (years)
<60
60-79
>79
-
Shock
BP >100 mm Hg Pulse <100 bpm
BP >100 mm Hg Pulse >100 bpm
BP <100 mm Hg Pulse >100 bpm
-
Comorbidity
None
-
Cardiac disease, any other major comorbidity
Renal failure, liver failure, disseminated malignancy
Endoscopic diagnosis
Mallory-Weiss tear, no lesion
All other diagnoses
Malignancy of the upper GI tract
-
Major SRH
None, or dark spots
-
Blood in the upper GI tract, adherent clot or spurting vessel
-
BP = blood pressure; GI = gastrointestinal; SRH = stigmata of recent haemorrhage


• There are various risk assessment scores, but the most widely used and the best validated is the Rockall score. The score is calculated by adding independent risk factors shown in Table 1.

Table 2. Rebleed and mortality risk according to Rockall score

Risk score
Predicted rebleed (%)
Predicted mortality (%)
0
5
0
1
3
0
2
5
0
3
11
3
4
14
5
5
24
11
6
33
17
7
44
27
8+
42
41


Remove blood clot from the ulcer base using washing devices and snares followed by endoscopic therapy
Blood clots should be removed as vigorously as possible to identify the underlying pathology and then to treat it.
This risks exacerbating bleeding, but the advantages of clearly identifying the underlying cause and then applying endoscopic therapy outweigh this potential disadvantage.

Table 3 shows that patients who have major endoscopic stigmata associated with a peptic ulcer are at significant risk of rebleeding in hospital. It is now mandatory that patients with major endoscopic stigmata undergo therapeutic endoscopy. This reduces the need for urgent surgery and probably reduces hospital mortality.

Table 3. Risk of rebleeding with stigmata of recent haemorrhage

Stigmata of recent haemorrhage
Risk of rebleeding (%)
None
0-5
Red or black spots
5
Oozing
7-10
Adherent blood clot
33
Non-bleeding visible vessel
50
Spurting haemorrhage
90


intravenous ranitidine as a constant infusion
This will not elevate intragastric pH sufficiently.

Colonoscopy

This may reveal a colon cancer or, providing bowel preparation is optimal, may show an arteriovenous malformation (AVM) (or angiodysplasia).
A technetium-99m labelled red cell scan
For this scan to be diagnostic there must be rapid acute bleeding resulting in pooling of labelled blood within the gut on gamma scanning.

Meckel's radionuclide scan

This would be a reasonable test in a teenager, but there is a very low chance of a positive diagnosis in an elderly person.
Mesenteric angiography
Angiography may be positive when bleeding exceeds 1 ml/min and is a useful investigation for severe acute bleeding. Having said that, in expert hands angiodysplasia may be suggested by a vascular blush and prominent draining veins within the region of the caecum and ascending colon on angiography.

Capsule enteroscopy

This is the investigation of choice for obscure slow gastrointestinal bleeding. It will demonstrate the whole gastrointestinal tract. Enteroscopy using a small bowel endoscope is an alternative.

Enteroscopy and thermal ablation

Ablation using multipolar coagulation, argon plasma coagulation, or a heater probe is effective and safe with only a low risk of perforation. "Double balloon" enteroscopes can be used to visualise and treat lesions throughout the great majority of the entire small bowel.
Oestrogen tablets
Previous reports of the effectiveness of oestrogen tablets have not been validated.
AVMs


The most common causes of significant upper gastrointestinal haemorrhage are:
Peptic ulcer - around 35% of cases
Oesophagitis - usually with hiatus hernia; often leading, insidiously to chronic iron deficiency
Gastritis and duodenitis - usually as a consequence of NSAIDs or H pylori
Oesophageal varices - 11% of cases) cause recurrent acute upper gastrointestinal bleeding. Patients usually have clinical and biochemical evidence of liver disease
Portal hypertensive gastropathy - usually in cirrhotic patients
Gastric or oesophageal neoplasia - particularly gastric cancer

Vascular malformations

Hereditary haemorrhagic telangiectasia
Gastric antral vascular ectasia
AVMs
Aorto-duodenal fistulae following aortic graft insertion.
In addition, you should consider and eliminate lower gastrointestinal causes:
Colonic cancer (particularly caecal)
Diverticular disease - the commonest cause of severe recurrent acute lower gastrointestinal bleeding
Vascular malformations (angiodysplasia)
Inflammatory bowel disease.

Start terlipressin and antibiotics

Long acting vasopressin analogues (glypressin and terlipressin) reduce splanchnic blood flow and thereby diminish portal pressure. Their use is associated with reduced bleeding and while this in itself does not improve mortality, it does make endoscopic haemostasis more easily achievable. Broad spectrum intravenous antibiotics are associated with reduction of re-bleeding and with improved mortality.


high dose omeprazole infusion
High dose intravenous proton pump inhibitors should only be prescribed after endoscopic therapy for a bleeding peptic ulcer. There is no place for their use prior to endoscopy or as adjunctive therapy for varices.
Sengstaken tube
The Sengstaken tube is required only rarely in patients with oesophageal variceal bleeding, and is indicated only when endoscopic therapy fails. You shouldn't insert one before doing an endoscopy.

You should arrange transfer to HDU or ITU

Nursing and medical management are demanding and can be adequately achieved only in these environments. Pulmonary aspiration, trauma to the oesophagus caused by the confused patient attempting to remove the inflated balloon, uncontrolled variceal bleeding, and increasing hepatic encephalopathy are among many of the complications that can occur after tube insertion. In the majority of cases endotracheal intubation and anaesthesia are required to safely manage the patient.
Urgent endoscopy shows large, actively bleeding oesophageal varices. Rubber bands are applied, but severe bleeding persists. A Sengstaken tube is inserted.

Sengstaken tube : variceal bleeding is controlled by inflation of the gastric balloon alone (with 250 ml of air). If bleeding persists the oesophageal balloon is inflated. Normal portal pressure is <10 mm Hg; maximal pressure in portal hypertensive patients is never >30 mm Hg, therefore a pressure of 40 mm Hg is sufficient. Higher pressures risk oesophageal necrosis.
It is wise to "rest" the oesophagus by deflating the oesophageal balloon for 5 minutes every hour.

Sengstaken tube

After 12-24 hours the tube should be removed and endoscopy undertaken with a view to further banding or injection sclerotherapy.
Tamponade is a bridge between uncontrolled active bleeding and definitive haemostatic therapy (usually variceal band ligation).

Banding or sclerosant injection of the gastric varices

For technical reasons is not possible to band gastric varices in most cases. Sclerotherapy does not stop gastric variceal bleeding, although injection with thrombin or fibrin glue may be effective.

Urgent insertion of a transjugular intrahepatic portasystemic shunt (TIPS)

TIPS is the treatment of choice for gastric varices (although these sometimes respond to injection with tissue adhesives or thrombin) and for oesophageal varices that bleed despite endo-therapy.


Oesophageal transection
This operation has an unacceptably high mortality rate and is less effective than TIPS.

Learning bite

Not all abdominal pain and vomiting is due to gastrointestinal bleeding. Acute pancreatitis is part of the differential diagnosis. Occasionally an x ray may help. For example, an isolated loop of duodenum that is dilated - the sentinel loop sign - suggests acute pancreatitis.