andrew rochford undergraduate teaching -...
TRANSCRIPT
Acute Upper GI Bleed
• Case History
– 66 year old ♂
– Intermittent dyspepsia (takes Gavison)
– Recently much worse with vomiting
– Episode of fresh malaena
• What else do you need to know?
Additional information
• History– Previous peptic ulceration
– PMHx
– DHx• Aspirin / NSAIDs, Anticoagulation
• Steroids, Ca channel blockers, theophylline, nitrates
• Are they already on a PPI?
• Examination– Heart rate
– Blood pressure (including postural)
– Abdominal examination (inc. digital rectal exam)
Case History - 66 year old ♂
• PMHx
– Ischaemic Heart Disease
• DHx
– ACEI, B Blocker, Aspirin
• On examination
– HR 100 reg
– SBP 110
– Malaena on DRE
• Hb 9.2 INR 1.2 Urea 12
Facts & Figures
• Incidence of 50 – 150 per 100 000 per annum
– Increased risk in low socioeconomic groups
• Significant mortality & morbidity
Rockall et al 1993/4 AUGIB Audit BSG/NBS ‘07
Total numbers 4185 6750
Overall mortality 14% 10%
New Admissions 11% 7%
In patients 33% 26%
Surgery 7% 2%
AUGIB BSG/NBS ‘07
• 43% Transfused
• 60% Out of hours
• 26% Did not have an inpatient OGD
• Varices 8% from 4%
• Only 19% of patients had documented evidence of risk stratification
Rockall Score
Rockall, T A et al. Risk assessment after acute gastrointestinal haemorrhage BMJ 1995;311:222-226Palmer KR et al. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51(Suppl IV):iv1-iv16
Aetiology
• 50% of patients with documented varices will bleed from another source
Rockall, T A et al. BMJ 1995;311:222-226
Scoring Systems
• Forrest scoring system
(endoscopic findings) 1974
• Baylor bleeding score 1993
• Rockall Score 1996
• Cedars-Sinai medical centre predictive index1996
• Blatchford score 2000
Endoscopic stigmata
“5% of bleeding will be out of the reach of an endoscope”
Stigmata Prevalance (%) Rebleed (%)
Arterial Bleed 10 90
Visible vessel 25 50
Adherent clot 10 25
Clean ulcer base 35 <5
Blockson JM et al Surg Endosc 2004;18:186-92
Risk Stratification
Minor/
Moderate
• Young
• No co-morbidity
• No shock
• Hb >10
• May NOT need OGD
Major
• Old
• Co-morbidity
• Shocked
• Hb <10
Further Management
‘The first priority in management is to correct fluid losses and restore blood pressure’
Palmer KR et al. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51(Suppl IV):iv1-iv16
Patient Management
• A B C D E
• IV access & bloods
• Estimate severity of bleeding
– Mild / Moderate
– Severe
• Pharmacological management
Pharmacological Management• Fluid resuscitation (including blood)
– AUGIB accounts for 13% of RBC transfusions in UK (Wallis, 2006)
• PPI – 80mg Omeprazole po (mild/moderate – 61p)– 80mg Omeprazole iv (severe - £10.42)
• Correct any clotting abnormalities– Vitamin K, FFP, Platelets, Tranexamic acid
• Prokinetic– Metoclopramide and / or Erythromycin
• Terlipressin (1g qds iv)– If varices suspected– Marked caution with ischaemic heart disease
Proton Pump Inhibitors
• ↑ pH of stomach
– Platelet / clot lysis if pH <6
• No evidence for H2 Antagonists
• Effects re-bleeding & surgery *
– No benefit on overall mortality
• Debate about route of administration
– iv if NBM
– iv infusion if bleeding vessel at endoscopy
• Evidence base often flawed* If bleeding vessel seen at endoscopy
Additional Management
• Endoscopy– Recommend dual endoscopic therapy for bleeding ulcers
• Surgery– Failed endoscopic haemostasis
– Endoscopic re-bleeding despite ‘successful’ endotherapy
– One vs. Two attempts
• Helicobacter pylori eradication
• Sengstaken-Blakemore tube:– Uncontrolled variceal bleed
Severe
• Admit to HDU
• Inform surgeons & anaesthetists
• Catheterise
• IV PPI
– Infusion for 72 hrs only if stigmata of high risk of re-bleed on endoscopy
• NBM
• Central venous access
• OGD when haemodynamically stable
Key References
1. Rockall TA, Logan RFA, Devlin HB et al. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. BMJ 1995; 331:222-6
2. Rockall TA, Logan RFA et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-321
3. Palmer KR et al. Non-variceal upper gastrointestinal haemorrhage: guidelines. Gut 2002;51(Suppl IV):iv1-iv16
4. National Confidential Enquiry into Patient Outcome and Death. Scoping our practice: the 2004 report of the National Confidential Enquiry into Patient Outcome and Death. London: NCEPOD, 2004
5. Dallal HJ & Palmer KR. ABC of the upper gastrointestinal tract: upper gastrointestinal haemorrhage.BMJ 2001;323:1115-7
GI Bleed Summary
• Triage according to severity of the bleed
• Resuscitate the patient
• Appropriate pharmacological management
• Early endoscopy
• Inform surgical / anaesthetic colleagues early