UPPER GASTROINTESTINAL BLEEDING G.C. Sturniolo Nicoletta Merlini Dipartimento di Scienze Chirurgiche e Gastroenterologiche Sezione di Gastroenterologia

ACUTE UPPER GI BLEEDING INCIDENCE: 50 to 150 cases per 105 per year In UK 25.000 hospital admission each year Palmer, PMJ 2004

AUGIB ETIOLOGY Peptic ulcer disease Oesophageal/gastric varices Mallory-Weiss tear Oesophagitis Duodenitis/gastritis/erosions Vascular (Angiodysplasia, Dieulafoy) Tumours Aortoenteric fistula

ACUTE UPPER GI BLEEDING Adapted from Palmer, PMJ 2004

MORTALITY Mortality % 4153 upper GI bleeding Rockall, BMJ 1995 > 90 21-30 31-40 41-50 51-60 61-70 71-80 81-90 Rockall, BMJ 1995

and mortality related to the source of bleeding MORTALITY in UGIB Hospital mortality and mortality related to the source of bleeding in 362 UGIB 45,5% 29,4% 22,7% 20% 9,1% 5,9% 3,8% 0% Klebl, Int J Colorectal Dis 2005

MORTALITY in UGIB Mortality of patients during hospitalization 40% p < 0,05 11% Bleeding only before admission Bleeding before + after admission Adapted from Palmer, PMJ 2004

MORTALITY FOR UGIB: Time Trend 1996 19,5% p=0,05 1996 2000 p=0,03 11,7% 11,1% 2000 7,2% Fiore, Eur J Gastr Hep 2005

UGIB: Diagnostic Endoscopy Identifies the bleeding lesions >95% of sensitivity and specificity Doesn’t alter patient outcome: Morbidity Mortality Transfusions Length of stay Surgery Peterson, NEJM 1981 Cappell, Med Clin N Am 2002

UGIB: Therapeutic Endoscopy Only patients with persisten or recurrent bleeding 80% patients don’t have further bleeding Optimal utilization IDENTIFY HIGH RISK PATIENTS

to assess risk of mortality and rebleeding UGIB: ROCKALL SCORE Developed in 1996 to assess risk of mortality and rebleeding in UGIB patients Rockall, BMJ 1996 Rockall risk score Variable Score 0 Score 1 Score 2 Score 3 AGE SHOCK CO-MORBID DIAGNOS MAJOR SRH < 60 None Mallory-Weiss No lesions None or dark spots 60-79 Pulse > 100 bpm - All other diagnoses > 80 Fc>100,PAOs <100 Cardiac failure Malignancy upper GI Blood in upper GI tract, blood clot Renal,liver failure

UGIB: ROCKALL SCORE Retrospective study, 222 patients Distribution of Rockall Score 7 5 4 6 8 % of patients 9 3 10 2 Bessa, DLD 2006

UGIB: ROCKALL SCORE Retrospective study, 222 patients Rebleeding Risk Mortality Risk p < 0,001 p = ns Rockall < 5 Rockall > 6 Rockall < 5 Rockall > 6 Bessa, DLD 2006

UGIB WHICH PATIENTS ARE MORE LIKELY TO REBLEED?

UGIB: Clinical Risk Large volume bleeding Shock Age > 60 years Bleeding onset after admission Comorbidity Variceal Bleeding

Scoring Systems for UGIB Baylor bleeding score (1993) Cedars-Sinai predictive index (1996) Rockall Score (1996) Blatchford Score (2000) Das, Gastrointest Endosc 2004

UGIB: Blatchford Score Derived from clinical information at presentation such as: Urea Hb Blood pressure Comorbidity (syncope, melena, heart and/or liver disease) Blatchford, Lancet 2000

“CLINICAL INTERVENTION” BLATCHFORD vs ROCKALL BETTER ROC FOR “CLINICAL INTERVENTION” Blatchford, Lancet 2000

PEPTIC ULCERS CLASSIFICATION FORREST CLASSIFICATION ACUTE HEMORRHAGE Forrest I a Arterial, spurting hemorrhage Forrest I b Oozing hemorrhage SIGNS OF RECENT HEMORRHAGE Forrest II a Visible vessel Forrest II b Adherent clot Forrest II c Hematin covered lesion LESIONS WITHOUT RECENT BLEEDING Forrest III No signs of recent hemorrhage

Forrest IIb Forrest IIa

FORREST CLASSIFICATION Forrest 1a Spurting bleeding Forrest 1b Non-spurting active bleeding Forrest 2a Non-bleeding visible vessel Forrest 2b Non-bleeding with adherent clot Forrest 2c Forrest 3 Ulcer with haematin-covered base Ulcer with clean base

PEPTIC ULCERS: RISK FACTORS? Male, Advanced age History of ulcer disease Helicobacter Pylori Corticosteroids NSAIDs Blood-thinning drugs

Endoscopy and endoscopic therapy MANAGEMENT OF UGIB Resuscitation Endoscopy and endoscopic therapy Drug Therapy

Endoscopy and endoscopic therapy MANAGEMENT OF UGIB Resuscitation Endoscopy and endoscopic therapy Drug Therapy

RESUSCITATION Airway, Breathing, Circulation Shocked Actively bleeding Central Venous Pressure (elderly and cardiopathic) Crystalloids (carefully in liver disease!) Colloids in major hypotension Blood transfusion Shocked Actively bleeding Hb < 10 g/dL Palmer, PMJ 2004

WHEN SHOULD WE TRANSFUSE PATIENTS? Age > 60 years Hb < 8.2 g/dL Blood Transfusion Cardiologic Evaluation cTropI Curve Gastro PD, BLISC

Endoscopy and endoscopic therapy MANAGEMENT OF UGIB Resuscitation Endoscopy and endoscopic therapy Drug Therapy

UGIB: TO SCOPE Early endoscopy identifies and treats patients with high risk of rebleed improving patient outcomes PPI therapy alone is not as effective as endoscopic therapy for high risk lesions

UGIB: NOT TO SCOPE No benefit from early endoscopy if the findings do not change patient care

Time with intragastric pH>4 / 24h DRUG THERAPY IV PPI vs IV RANITIDINE Time with intragastric pH>4 / 24h 96% 93% 67% p<0,001 43% Merki, Gastroenterology 1996

MANAGEMENT OF NON VARICEAL BLEEDING Non-variceal, upper GI bleeding IV PPI bolus + infusion Upper Endoscopy High-risk stigmata Low-risk stigmata Endo therapy + IV PPI Oral PPI therapy Triadafilopoulos, Alim Pharm Ther 2005

BLEEDING PREVALENCE: 30-40% MORTALITY I BLEEDING: 20-45% OESOPHAGEAL VARICES 80-90% CIRRHOSIS BLEEDING PREVALENCE: 30-40% MORTALITY I BLEEDING: 20-45% PRIMARY PREVENTION SECONDARY PREVENTION TREATMENT ACUTE BLEEDING

CIRRHOSIS SMALL VARICES LARGE VARICES REBLEEDING PRIMARY PREVENTION INCIDENCE/YEAR 5-30% INCIDENCE/YEAR 5-50% MORTALITY 30-50% INCIDENCE/YEAR 5-10% CIRRHOSIS SMALL VARICES ACUTE BLEEDING LARGE VARICES REBLEEDING 60% 1 YEAR PRIMARY PREVENTION  50% BLEEDING 25-45% MORTALITY’

RISK FACTORS HIGHER BLEEDING RISK CHILD B-C EXTENSION (63% Ls vs 45% Li) DIMENSION (F1,15%;F2,32%;F3,68%) RED WALL MARK (red spots e wall marking 76% vs 17% without) COLOR (blue 80% vs white 45%) PORTAL VEIN PRESSURE (> 12 mmHg) HIGHER BLEEDING RISK

VARICEAL BLEEDING VASOACTIVE ANTIBIOTIC DRUGS EGDS IN 12 HRS RESUSCITATION PLASMA EXPANDERS UEC VARICEAL BLEEDING VASOACTIVE DRUGS ANTIBIOTIC De Franchis, J Hepatol 2000

MEDICAL TREATMENT ANTIBIOTICS INFECTIONS  35-66% BLEEDING CIRRHOTICS UTI 12-29% E.Coli + Klebsiella SBP 7-23% Gram -/+ PULMONARY INFECTIONS 6-10% SEPSI 4-11% Dell’Era, APT 2004

INFECTIONS  BLEEDING CONTROL FAILURE  MORTALITY RELATED BLEEDING PREDICTIVE FACTOR OF REBLEEDING

MEDICAL TERATMENT VASOACTIVE DRUGS TERLIPRESSIN 2 mg e.v. qd 4-6 hrs per 24 hrs then 1 mg e.v. qd 6 hrs per 4 days

TAKE HOME MESSAGES EGDS VASOACTIVE DRUGS, BLOOD TRASFUSION RESUSCITATION, COLLOIDS, ANTIBIOTICS EGDS VARICEAL BAND LIGATION SCLEROTHERAPY MEDICAL TREATMENT Failure Vasoactive drugs (5 days long) II EGDS Failure BLAKEMORE Surgery (child A) TIPS (child B,C) Lata J et al Dig Dis 2003