1. Hussien Mohammed Jumaah CABM Lecturer in internal medicine Mosul College of Medicine Monday, 4 April, 2016 Acute upper gastrointestinal haemorrhage Copyright © 2015

2. Gastrointestinal bleeding (GIB), upper GIB (UGIB) ~1.5–2 times more common than lower GIB (LGIB) GIB presents as either overt or occult bleeding. Overt GIB is manifested by hematemesis, vomitus of red blood or “coffee-grounds” material; melena, black, tarry, foul-smelling stool; and/or hematochezia, passage of bright red or maroon blood from the rectum. Occult GIB may be identified in the absence of overt bleeding when patients present with symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea; or when routine diagnostic evaluation reveals iron deficiency anemia or a positive fecal occult blood test. Copyright © 2015

3. Sources of Bleeding in Patients Hospitalized for Upper Gastrointestinal Bleeding Copyright © 2015

4. Evaluation and Management of UGIB At presentation, patients are generally stratified as higher or lower risk for further bleeding and death. Baseline characteristics predictive of rebleeding and death include hemodynamic compromise (tachycardia or hypotension), increasing age, and comorbidities. PPI infusion may be considered at presentation: it decreases high risk ulcer stigmata (e.g., active bleeding) and need for endoscopic therapy but does not improve clinical outcomes such as further bleeding, surgery, or death. Treatment to improve endoscopic visualization with the promotility agent erythromycin, 250 mg IV ~30 min before endoscopy, also may be considered. Copyright © 2015

5. Approach to the patient : Gastrointestinal Bleeding Initial assessment Measurement of the heart rate and blood pressure is the best way to initially assess a patient with GIB. Clinically significant bleeding leads to postural changes in heart rate or blood pressure, tachycardia, and, finally, recumbent hypotension. In contrast, the hemoglobin does not fall immediately with acute GIB, due to proportionate reductions in plasma and red cell volumes (i.e., “people bleed whole blood”). Thus, hemoglobin may be normal or only minimally decreased at the initial presentation. As extravascular fluid enters the vascular space to restore volume, the hemoglobin falls, but this process may take up to 72 h.

6. Approach to patient Gastrointestinal Bleeding Initial assessment (continued) Transfusion is recommended when the hemoglobin drops < 7 g/dL, based on a large randomized trial showing this restrictive transfusion strategy decreases rebleeding and death in acute UGIB compared with a transfusion threshold of 9 g/dL. Patients with slow, chronic GIB may have very low hemoglobin values despite normal blood pressure and heart rate. Copyright © 2015

7. UGIB : Peptic ulcers One-third of patients with active bleeding or a nonbleeding visible vessel have further bleeding that requires urgent surgery if they are treated conservatively. These patients benefit from endoscopic therapy with bipolar electrocoagulation, heater probe, injection therapy (e.g., absolute alcohol, 1:10,000 epinephrine), and/or clips with reductions in bleeding, hospital stay, mortality, and costs. In contrast, patients with clean-based ulcers have rates of recurrent bleeding approaching zero. If stable with no other reason for hospitalization, such patients may be discharged home after endoscopy. Copyright © 2015

8. UGIB : Peptic ulcers (continued) Patients without clean-based ulcers usually remain in the hospital for 3 days because most episodes of recurrent bleeding occur within 3 days. Randomized controlled trials document that high-dose, constant infusion IV proton pump inhibitor (PPI) (80-mg bolus and 8-mg/h infusion), designed to sustain intragastric pH >6 and enhance clot stability, decreases further bleeding and mortality in patients with high-risk ulcers (active bleeding, nonbleeding visible vessel, adherent clot) when given after endoscopic therapy. Copyright © 2015

9. UGIB : Peptic ulcers (continued) Approximately one third of patients with bleeding ulcers will rebleed within the next 1–2 years if no preventive strategies are employed. Prevention of recurrent bleeding focuses on the three main factors in ulcer pathogenesis, Helicobacter pylori, NSAIDs, and acid. Eradication of H. pylori in patients with bleeding ulcers decreases rates of rebleeding to <5%. If a bleeding ulcer develops in a patient taking NSAIDs, the NSAIDs should be discontinued. If NSAIDs must be given, a cyclooxygenase 2 (COX-2) selective inhibitor (coxib) plus a PPI should be used. Copyright © 2015

10. Patients with major bleeding and high risk endoscopic findings (e.g., varices, ulcers with active bleeding or a visible vessel) benefit from endoscopic hemostatic therapy, whereas patients with low-risk lesions (e.g., clean-based ulcers, nonbleeding Mallory-Weiss tears, erosive or hemorrhagic gastropathy) who have stable vital signs and hemoglobin and no other medical problems can be discharged home. Copyright © 2015

11. Patients with established cardiovascular disease who develop bleeding ulcers while taking low-dose aspirin should restart aspirin as soon as possible after their bleeding episode (1–7 days). A randomized trial showed that failure to restart aspirin was associated with no significant difference in rebleeding (5% vs. 10% at 30 days) but a significant increase in mortality at 30 days (9% vs. 1%) and 8 weeks (13% vs. 1%) compared with immediate reinstitution of aspirin. Patients with bleeding ulcers unrelated to H. pylori or NSAIDs should remain on PPI therapy indefinitely. Copyright © 2015

12. Differentiation of UGIB from LGIB Hematemesis indicates an upper GI source of bleeding (above the ligament of Treitz). Melena indicates blood has been present in the GI tract for at least 14 h. Hematochezia usually represents a lower GI source of bleeding, although an upper GI lesion may bleed so briskly that blood transits the bowel before melena develops. Bleeding lesions of the small bowel may present as melena or hematochezia. Other clues to UGIB include hyperactive bowel sounds and an elevated blood urea nitrogen (volume depletion and blood proteins absorbed in the small intestine). Copyright © 2015

13. Suggested algorithm for patients with acute upper gastrointestinal (GI) bleeding. Copyright © 2015

14. Cirrhotic patients presenting with UGIB should be placed on antibiotics (e.g., quinolone, ceftriaxone) and started on a vasoactive medication (octreotide, terlipressin, somatostatin, vapreotide) upon presentation, even before endoscopy. Antibiotics decrease bacterial infections, rebleeding, and mortality in this population, and vasoactive medications appear to improve control of bleeding in the first 12 h after presentation. Upper endoscopy should be performed within 24 h in most patients with UGIB. Copyright © 2015

15. Suggested algorithm for patients with acute lower gastrointestinal (GI) bleeding. *Some suggest colonoscopy for any degree of rectal bleeding in patients <40 years as well. ^ If upper GI endoscopy reveals definite source, no further evaluation is needed. † If massive bleeding does not allow time for colonic lavage, proceed to angiography. Copyright © 2015

17. Acute upper gastrointestinal haemorrhage This is the most common gastrointestinal emergency. The mortality of patients admitted to hospital is about 10%. Risk scoring systems have been developed to stratify risk of needing endoscopic therapy or a poor outcome.The advantage of the Blatchford score is that it may be used before endoscopy to predict the need for intervention to treat bleeding. Low scores (2 or less) are associated with a very low risk of adverse outcome.

18. Acute upper gastrointestinal haemorrhage Clinical assessment Haematemesis is red with clots when bleeding is rapid and profuse, or black (‘coffee grounds’) when less severe. Syncope may occur and is due to hypotension from intravascular volume depletion. Symptoms of anaemia suggest chronic bleeding. Melaena is the passage of black, tarry stools containing altered blood; it is usually caused by bleeding from the upper gastrointestinal tract, although haemorrhage from the right side of the colon is occasionally responsible. Severe acute upper gastrointestinal bleeding can sometimes cause maroon or bright red stool.

19. Causes of acute upper gastrointestinal haemorrhage

20. Acute upper gastrointestinal haemorrhage Management 1. Intravenous access using at least one large-bore cannula. 2. Initial clinical assessment Define circulatory status. Severe bleeding causes tachycardia, hypotension and oliguria. The patient is cold and sweating, and may be agitated. Seek evidence of liver disease. Jaundice, cutaneous stigmata, hepatosplenomegaly and ascites.

21. Acute upper gastrointestinal haemorrhage Management (continued) Identify comorbidity. cardiorespiratory, cerebrovascular or renal disease is important, because these may be worsened by acute bleeding and because they increase the hazards of endoscopy and surgical operations. These factors can be combined using the Blatchford score, which can be calculated at the bedside. A score of less than 3 is associated with a good prognosis, while progressively higher scores are associated with poorer outcomes.

22. Acute upper gastrointestinal haemorrhage Management (continued) 3. Basic investigations Full blood count. Urea and electrolytes. Liver function tests. Prothrombin time. Cross-matching. At least 2 units of blood should be cross- matched. 4. Resuscitation IV crystalloid fluids given to raise the blood pressure, and blood should be transfused when the patient is actively bleeding with low blood pressure and tachycardia.

23. Acute upper gastrointestinal haemorrhage Management (continued) Comorbidities should be managed as appropriate. Patients with suspected chronic liver disease should receive broad-spectrum antibiotics. Central venous pressure (CVP) monitoring may be useful in severe bleeding, particularly in patients with cardiac disease, to assist in defining the volume of fluid replacement and in identifying rebleeding. 5. Oxygen This should be given to all patients in shock. 6. Endoscopy This should be carried out after adequate resuscitation, ideally within 24 hours, and will yield a diagnosis in 80% of cases.

24. Acute upper gastrointestinal haemorrhage Management (continued) Patients who are found to have major endoscopic stigmata of recent haemorrhage can be treated endoscopically using a thermal or mechanical modality, such as a ‘heater probe’ or endoscopic clips, combined with injection of dilute adrenaline (epinephrine) into the bleeding point (‘dual therapy’). This may stop active bleeding and, combined with IV proton pump inhibitor (PPI) therapy, prevent rebleeding, thus avoiding the need for surgery. Patients found to have bled from varices should be treated by band ligation.

25. Acute upper gastrointestinal haemorrhage Management (continued) 7. Monitoring Patients should be closely observed, with hourly measurements of pulse, blood pressure and urine output. 8. Surgery Surgery is indicated when endoscopic haemostasis fails to stop active bleeding and if rebleeding occurs on one occasion in an elderly or frail patient, or twice in a younger, fitter patient. If available, angiographic embolisation is an effective alternative to surgery in frail patients.

26. Acute upper gastrointestinal haemorrhage Management (continued) The choice of operation depends on the site and diagnosis of the bleeding lesion. Duodenal ulcers are treated by under-running, with or without pyloroplasty. Underrunning for gastric ulcers can also be done (a biopsy must be taken to exclude carcinoma). Local excision may be performed, but when neither is possible, partial gastrectomy is required. Following surgery for ulcer bleeding, all should be treated with H. pylori eradication therapy if they test positive for it, Successful eradication should be confirmed by urea breath or faecal antigen testing, and should avoid NSAIDs.

27. Major stigmata of recent haemorrhage and endoscopic treatment. A Active arterial spurting from a gastric ulcer. An endoscopic clip is about to be placed on the bleeding vessel. When associated with shock, 80% of cases will continue to bleed or rebleed. B ‘Visible vessel’ (arrow). In reality, this is a pseudoaneurysm of the feeding artery seen here in a pre-pyloric peptic ulcer. It carries a 50% chance of rebleeding. C Haemostasis is achieved after endoscopic clipping of the bleeding vessel in the duodenum.

28. Single versus dual modality endoscopic therapy in high-risk bleeding ulcers

29. Emergency management of acute non-variceal upper gastrointestinal haemorrhage

30. Modified Blatchford score: risk stratification in acute upper GI bleeding