Management of a Pt with Hematemesis Dr. Salem Mohammad Bazarah MD, M.Ed, FACP, FRCPC, FRCPC (GI) & PhD Management of a Pt with Hematemesis

A common medical condition 250,000 – 500,000 admissions/year US UGI bleeding incidence 100/100,000 adults Incidence increases 20-30 fold from third to ninth decade of life LGI bleeding incidence 20/100,000 adults Overwhelmingly disease of the elderly GI bleeding stops spontaneously in 80 %

Morbidity Data Majority will receive blood transfusions 2 – 10 % require urgent surgery to arrest bleeding Average LOS 4 – 7 days Mortality rates for UGI bleeding 2 – 15 % Mortality for patients who develop bleeding after admission to hospital for another reason is 20 – 30 %

Costs Average hospital costs exceed $ 5,000 per admission Most of this for hospital bed and ICU stays rather than physician fees, blood products, diagnostic tests, or medications Reduction of hospital admissions and LOS has greatest potential to reduce costs

UGI bleeding:Nomenclature Hematemesis 25 % Melena alone 25 %, 50 – 100 cc of blood will render stool melenic Hematochezia 15 %, seen in massive UGI hemorrhage “Red blood” hematemesis “Coffee ground” emesis

Indications for Hospitalization and Intensive Care Traditional: Endoscopy on the day of admission or on the day after Recent studies: Complete endoscopic risk stratification PRIOR to admission Between 25- 30 % of patients with UGI bleeding could be discharged from the Emergency Department

Predictors of Outcome in UGI bleeding Clinical Endoscopic Age > 60 y Low risk endoscopic findings Hemodynamic instability High risk endoscopic findings Comorbidities Hematemesis (red blood) Coagulopathy

Ulcer Appearance and Prognosis Prevalence % Rebleed % Mortality % Clean base 42 5 2 Flat spot 20 10 3 Clot 17 22 7 Visible vessel 43 11 Active bleeding 18 55

History 45 yrs male with 1 day hx of vomiting blood

Approach Assess the severity Resuscitate Establish the site of bleeding Endoscopic intervention Reassess severity: liase with surgical team Medical treatment Indications for surgery

Assessing severity: Rockall criteria Criterion Score Age <60 years 0 60-79 yrs 1 >80 years 2 Shock None 0 Pulse & sBP >100 1 sBP <100 2 Co-morbidity None 0 Cardiac/any major 2 Renal/liver/malig. 3 Total initial score (max = 7)

Implications of initial score Initial risk score (pre-endoscopy) Score Mortality 0 0.2% 1 2.4% 2 5.6% 3 11.0% 4 24.6% 5 39.6% 6 48.9% 7 50.0% Rockall TA et al Gut 1996; 38: 316-21

Resuscitate Large bore intravenous cannula x 2 X-match 4 units, give colloid & transfuse if Fresh melaena on PR Postural hypotension >15mm/Hg sBP <100mmHg Cross match 6 units for Suspected variceal bleeding Otherwise group and save serum only

Resuscitation Indications for CVP Urea/creatinine ratio Rockall score > 3, first rebleed, or inadequate access Insert urinary catheter if CVP appropriate Urea/creatinine ratio If >unity (eg 12.4/90), then upper GI bleed likely Monitor Pulse & BP ‘?hrly’ Guide of halves: if pulse higher or BP lower than last recording, then halve the time to the next recording If pulse trend rises on 3 occasions, call senior cover

Establish site of bleeding Endoscopy on next available list Ideally <24hr Out of hours endoscopy If a surgical decision depends on the result Therefore consent ‘endoscopy, ?proceed’ Check endoscopy report for stigmata of recent haemorrhage intervention

Stigmata of recent haemorrhage Clean ulcer base (rebleed <1%) Black spots ulcer base (rebleed 5%)

Stigmata of recent haemorrhage Fresh clot (rebleed 30%) Visible vessel (rebleed 50%)

Stigmata of recent haemorrhage Bleeding vessel (rebleed 80%)

Upper GI Bleeding Klaus Gottlieb, MD, FACP, FACG

Source of bleeding Common DU (35%) GU (20%) Oesophagitis (6%) Mallory-Weiss (6%) No source found (20%) Uncommon/Rare Varices Tumour Aortoenteric fistula Dieulafoy Haemobilia Angiodysplasia

Do not prescribe iv ranitidine, or oral PPI until after endoscopy Intervention Endoscopic injection with Adrenaline 1:10 000, thrombin, sclerosant, or saline all halve the risk of rebleeding As good as heater probe, laser therapy Tranexamic acid 1g iv three times daily for 72hr reduces mortality Omeprazole 60mg iv stat and infusion 8mg/hr for 72hr may reduce mortality after endoscopic intervention Nothing else has been shown to work Do not prescribe iv ranitidine, or oral PPI until after endoscopy

Reassess severity: update Rockall Score Endoscopic diagnosis No lesion, or M-W tear 0 All other diagnoses 1 Malignancy of upper GI tract 2 Stigmata of recent haemorrhage None/haematin 0 Clot, visible vessel,blood in stomach 2 Final score after endoscopy (max 11)

Updated Rockall score Initial score (pre- endoscopy) Score Mortality 0 0.2% 1 2.4% 2 5.6% 3 11.0% 4 24.6% 5 39.6% 6 48.9% 7 50.0% Final score (after endoscopy) Score Mortality 0 0% 1 0% 2 0.2% 3 2.9% 4 5.3% 5 10.8% 6 27.0% 7 17.3 8+ 41.1%

Further management Liase with surgeons if After endoscopy Initial score >3 (ie if CVP necessary) Posterior duodenal ulcer Final Rockall score >4 After endoscopy Eat & drink if no stigmata, or haematin only Clear fluids for 12 hr if endoscopic intervention NBM only if haemostasis not secure (varices) Re-examine after 4-8hr for signs rebleeding Ring blood bank to keep blood available for 24hr after endoscopic intervention

Signs of rebleeding Rise in pulse rate Fall in CVP Decrease in hourly urine output Further haematemesis or fresh melaena Look at the patient as well as the charts! Act if rebleeding suspected FBC and transfuse Ensure large bore access, central line and catheter Call surgical team

Indications for surgery Early surgery (esp. elderly) assoc. with lower mortality Age over 60 years Transfusion >4 units in 24hr One rebleed Continued bleeding Age under 60 years Transfusion >8 units in 24hr Two rebleeds Decision not to operate should be taken by consultant

Special notes - Variceal bleeding Suspect variceal bleeding if….. - Alcohol Hx - Deranged LFT’s - Jaundice* - Hyponatraemia* - Ascites* - Coagulopathy - Low platelets - Previous Hx of varices*

Special notes – Variceal Bleeding Resuscitate Correct coagulopathy (FFP x 4 and vit K IV) Endoscopy and banding/sclerotherapy Glypressin 2mg iv stat and 1-2mg repeated 4hrly Treat other aspects of decompensation Ascites (spironolactone, no N/saline) Encephalopathy (lactulose, no sedation) Renal impairment (avoid hypovolaemia) Malnutrition (iv vitamins, fine bore feeding) Underlying liver disease (hepatic ‘screen’, aFP etc) Post-bleed prophylaxis

Summary Objective assessment (Rockall criteria) Resuscitation before endoscopy Monitor by rule of halves: look for trends No role for empirical acid suppression Critical appraisal of endoscopy report Liaise with surgeons early Discriminate between high & low risk patients