Management of acute upper GI haemorrhage

Causes Peptic ulcer 35-50% Gastroduodenal erosions 8-15% Oesophagitis 5-15% Varices 5-10% Mallory Weiss tear 15% Upper GI malignancies 1% Vascular malformations 5% Rare 5%

Initial resuscitation Two large bore cannulae and take sample Normal saline 1-2 lt fall of pulse/improved BP/adq urine Plasma expander if still shocked Blood transfusion - haematemesis/shock - Hb <10

Severity of bleed Current clinical scoring system( Rockall) for risk of re-bleed or death involves OGD So definition of mild/mod/severe remains a matter of clinical judgement

Mild to moderate bleed Pulse/BP normal Hb >10 Insignificant comorbidity Mostly <60 yrs General ward Allowed fluid if stable BP/pulse hourly Monitor urine volm Endoscopy next available list Early discharge

Excellent prognosis if no SRH/varices/malignancy Continued Excellent prognosis if no SRH/varices/malignancy Subsequent management May include H.Pylori eradication Use of acid suppressing treatment Advice concerning NSAIDs

Severe bleed Pulse>100 SBP < 100 Hb < 10 Significant comorbidity Mostly >60 yrs Preferably HDU Hrly BP/pulse/ urine volm Fasted Urgent endoscopy after resuscitation

Endoscopy in acute upper GI haemorrhage Semi-elective in minor and urgent in major bleed Only after initial resuscitation Best done in endoscopy unit But out of hours ,operating theatre with full resus. Equipment and anaesthetist may be better option Only expert endoscopists Consider ET tube to prevent aspiration

Endoscopic finding & subsequent management No SRH : general ward Varices : VBL/VScl Ulcer with SRH : endoscopic haemostasis 1.adrenaline inj 2.heat application 3.mechanical clips

Drug therpy for non-variceal principally ulcer bleed Evidence suggests following successful endoscopic treatment in patient presenting with major ulcer bleed high dose omeprazole stabilizes clot and prevents rebleed omeprazole 80mg iv stat followed by 8mg per hour infusion for upto 72 hrs

After endoscopy Close monitor to identify rebleed If stable after 6hrs allow light diet ( no data suggesting prolong fasting necessary) Repeat endoscopy If active rebleed If concern re optimal initial therapy (after 12-24 hrs)

Surgical intervention If endoscopic therapy unsuccessful In rebleed it is advisable to repeat endoscopy to confirm bleed and also try offer one more time of endoscopic therapy before considering surgery if it was initially successful In massive rebleed sometimes surgical intervention is needed straightway if initial OGD was unfavourable

Surgical options Duodenal ulcers Gastric ulcers Under running ±ligation of gastroduodenal/rt gastroepiploic arteries Gastrectomy to include the ulcer with Billroth I or II reconstruction Gastric ulcers Excised Parial gastrectomy Under running if elderly with poor condition

Follow up For ulcer bleeds standard ulcer healing treatment In most cases this also involves H.Pylori eradication Ulcer associated with NSAID -stop drug or choose the least damaging one Re-endoscope GU in 6wks to ensure healing. Not necessary for DU.

Additional points for variceal haemorrhage For no varix on initial endoscopy repeat 3yrly For grade 1 varix yearly F/U Primary prophylaxis with propranolol (80-160mg) for all grade 2/3 oesophageal varices If unsuitable for ppnl, VBL is next option ISMN

Acute management of variceal haemorrhage Antiobiotic prophylaxis for all patients ciprofloxacin 500mg BD for a week VBL is method of choice for OV VScl if above difficult or unavailable If endoscopy unavailable vasoconstrictor therapy or balloon tamponade with Sengstaken tube while more definitive therapy is arranged

continued Pharmacological therapy is with two major classes of drugs –vasopressin or its analogue terlipressin (glypressin) and somatostatin or its analogue octreotide Terlipressin is given as 2mg iv bolus followed by 1-2mg every 4-6 hrs for up to 72hrs

OV BLEED Controlled – banding eradication programme. One band /wk. F/U at 3& 6 month and then yearly Uncontrolled –balloon tamponade until further endoscopic treatment/ TIPSS/surgical intervention Choice of TIPSS or surgical intervention such as oesophageal transection depends on centre’s preference

GV bleed If IGV initial sclerotherapy with butyl-cyanoacrylate If unsuccessful balloon tamponade prior to more definitive treatment

Secondary prophylaxis of variceal haemorrhage banding eradication programme TIPSS Portocaval shunt surgery

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