By Mesenteric arterial circulation, Mesenteric microcirculation and barrier function, Mesenteric venous circulationLeave a Comment on Upper GI Bleeding (Haematemesis or blood in gastric aspirate)

Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%[1]. It is defined as hemorrhage originating from anywhere between the esophagus and the ligament of Treitz. It can present with hematemesis, melena, or hematochezia.

Feasibility/Equipment: The diagnosis and treatment of UGIB requires endoscopy, which is usually performed by a gastroenterologist or a surgeon. Endoscopy can identify the source of bleeding, estimate the risk of rebleeding, and provide hemostatic therapy. Endoscopy requires sedation, monitoring, and trained personnel. Other equipment that may be needed include blood products, intravenous fluids, vasoactive drugs, antibiotics, and proton pump inhibitors (PPIs).

Scoring information: There are several scoring systems that can help stratify the risk of UGIB and guide management. The most widely used are the Glasgow-Blatchford score (GBS) and the Rockall score. The GBS is based on clinical and laboratory parameters and can identify patients who are at very low risk of needing an intervention or death[2]. The Rockall score is based on age, comorbidities, endoscopic findings, and bleeding severity and can predict the risk of rebleeding and mortality[3].

Cost: The main drivers of cost in patients with upper GI bleeding are endoscopy and hospital stay as well as transfusion.

Evidence: There is a large body of evidence for the management of UGIB from randomized controlled trials, meta-analyses, systematic reviews, and clinical guidelines. Recommendations include the following points:

  • Patients with UGIB should be assessed for hemodynamic stability and resuscitated if necessary[5].
  • Patients with UGIB should undergo endoscopy within 24 hours of presentation[5].
  • Patients with UGIB should receive PPIs to reduce gastric acid secretion and prevent rebleeding[6].
  • Patients with UGIB due to peptic ulcer disease should receive endoscopic hemostasis with adrenaline injection combined with a mechanical or thermal method[7].
  • Patients with UGIB due to variceal bleeding should receive endoscopic band ligation or sclerotherapy and vasoactive drugs such as octreotide or terlipressin[8].
  • Patients with UGIB due to non-variceal bleeding who rebleed despite endoscopic treatment should be considered for interventional radiology or surgery[9].

Accuracy / measurement properties: ebleeding: This is defined as recurrent bleeding after initial hemostasis. The rate of rebleeding varies depending on the etiology and treatment of UGIB. A meta-analysis found that the rate of rebleeding was 14% for peptic ulcer disease, 20% for variceal bleeding, and 11% for non-variceal bleeding[10].

  • Mortality: This is defined as death from any cause within 30 days of UGIB. The mortality rate also varies depending on the etiology and treatment of UGIB. A meta-analysis found that the mortality rate was 10% for peptic ulcer disease, 15% for variceal bleeding, and 7% for non-variceal bleeding[10].
  • Correlation with other outcomes: There are several factors that can influence the outcomes of UGIB, such as age, comorbidities, shock, transfusion requirements, endoscopic findings, and treatment modalities. Some studies have found correlations between these factors and rebleeding or mortality. For example:
    • A study found that patients with UGIB who had a high GBS (>12) had a higher risk of rebleeding (odds ratio [OR] = 4.8) and mortality (OR = 6.9) than those with a low GBS (<6)[11].
    • A study found that patients with UGIB who received erythromycin before endoscopy had a lower risk of rebleeding (OR = 0.43) than those who did not[12].
    • A study found that patients with UGIB who received PPIs before endoscopy had a lower risk of mortality (OR = 0.54) than those who did not[13].
    • In a cohort of 540 critically ill patients assessed for a variety of gastrointestinal symptoms, signs and markers GI bleeding was not associated with increased mortality (HR 1.2 [0.26 – 5.54], p = 0.818) or 90 day (HR 1.17 [0.23 – 5.86])  [15].

References:

  1. Barkun AN, Bardou M, Kuipers EJ et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152(2):101-13.
  2. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356(9238):1318-21.
  3. Rockall TA, Logan RF, Devlin HB et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38(3):316-21.
  4. Hearnshaw SA, Logan RF, Palmer KR et al. Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit. Gut 2010;59(8):1022-9.
  5. Gralnek IM, Dumonceau JM, Kuipers EJ et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015;47(10):a1-46.
  6. Sreedharan A, Martin J, Leontiadis GI et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010;(7):CD005415.
  7. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107(3):345-60.
  8. Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 2010;362(9):823-32.
  9. Sung JJ, Lau JY, Ching JY et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann Intern Med 2010;152(1):1-9.
  10. Lanas A, Garcia-Rodriguez LA, Polo-Tomas M et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009;104(7):1633-41.
  11. Stanley AJ, Ashley D, Dalton HR et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 2009;373(9657):42-7.
  12. Pateron D, Vicaut E, Debuc E et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med 2011;57(6):582-9.
  13. Al-Sabah S, Barkun AN, Herba K et al. Cost-effectiveness of proton-pump inhibition before endoscopy in upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2008;6(4):418-25.
  14. Reintam Blaser A, Padar M, Mandul M, Elke G, Engel C, Fischer K, Giabicani M, Gold T, Hess B, Hiesmayr M et al: Development of the Gastrointestinal Dysfunction Score (GIDS) for critically ill patients – A prospective multicenter observational study (iSOFA study). Clin Nutr 2021, 40(8):4932-4940.

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