1. Matt Warren. Gastroenterology North Tyneside Hospital
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GI Bleeding
Matt Warren. Gastroenterology North Tyneside Hospital

2. Clinical Scenario Call from A&E middle grade
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Clinical Scenario
Call from A&E middle grade
Known varices – haematemesis
BP 85/42, pulse 43 (beta-blocked)
Have d/w Medical team
“get an urgent endoscopy”
Thoughts?

3. Introduction Common GI emergency Incidence 50 – 190 / 100 000 year
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Introduction
Common GI emergency
Incidence 50 – 190 / year
admissions per year
Overall mortality 7%
Mortality in IP 30%
Mortality hasn’t really changed but this reflects the fact that patients are older and sicker

4. Causes of UGI Bleed Peptic ulcer 35% Erosions 8-15% Oesophagitis 5-15%
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Causes of UGI Bleed
Peptic ulcer %
Erosions %
Oesophagitis %
Varices %
MW Tear %
Malignancy 1%

5. Emergency Treatment Variable Endoscopy rota Endoscopist experience
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Emergency Treatment
Variable
Endoscopy rota
Endoscopist experience
30% unable to manage variceal bleed
Interventional radiology / Surgery

6. What can you do? Make diagnosis Assess severity Resuscitate Treat
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What can you do?
Make diagnosis
Assess severity
Resuscitate
Treat

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By the end…
Guidelines
Confident in pre-endoscopy diagnosis and management
Considered some grey / difficult areas
Questions

8. But not…. Basics of resuscitation! Endoscopic management
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But not….
Basics of resuscitation!
Endoscopic management
Lots of boring trials

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11. Patient 54 year old – A&E Moderate haematemesis
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Patient
54 year old – A&E
Moderate haematemesis
Called to assess by A&E
ABC – done.
Approach….

12. 1. Make a diagnosis / assess severity
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1. Make a diagnosis / assess severity
Cause of bleeding
Variceal or Non-variceal (85% +) ?
High risk or low risk
Rockall or Blatchford
Varices automatically high risk

13. Task 1 Pairs Features that would make you suspect varices….
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Task 1
Pairs
Features that would make you suspect varices….

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15. Variceal Indicators Known varices… Known cirrhosis with PHT
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Variceal Indicators
Known varices…
Known cirrhosis with PHT
Stigmata advanced liver disease
Jaundice
Ascites
Encephalopathy

16. Patient No indicators of varices. Should you admit?
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Patient
No indicators of varices.
Should you admit?
How will you decide?

17. Task 2 Do you admit all GI bleeders?
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Task 2
Do you admit all GI bleeders?
How would you decide who to send home?

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19. NICE Recommends! Non-variceal (MW tear) low risk bleed
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NICE Recommends!
Non-variceal (MW tear) low risk bleed
Could send home for OP OGD / No OGD

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16% of patients had score 0 – Lancet 2009

21. We admit our patient Resuscitate as normal
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We admit our patient
Resuscitate as normal
Hb 8.4, Platelets 47, WCC 6.5
U&E normal, LFT normal
Any other bloods you’d like?

22. Patient Resuscitate as normal Hb 8.4, Platelets 47, WCC 6.5,
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Patient
Resuscitate as normal
Hb 8.4, Platelets 47, WCC 6.5,
U&E normal, LFT normal
Fib 0.8, INR 1.3

23. Task 3 Will you transfuse? Blood Platelets FFP
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Task 3
Will you transfuse?
Blood
Platelets
FFP

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NICE Recommends! (2)

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NICE Recommends (3)

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NICE recommends! (4)

28. Patient revisited… Resuscitate as normal
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Patient revisited…
Resuscitate as normal
Hb 8.4, Platelets 47, WCC 6.5,
U&E normal, LFT normal
Fib 0.8, INR 1.3
Nothing if stable
MTP protocol if massive bleed
FFP, Platelets if bleeds

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30. Some drugs……? You’ve made a diagnosis You’ve resuscitated / transfused
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Some drugs……?
You’ve made a diagnosis
You’ve resuscitated / transfused
You want to give some drugs!

31. Task 4 – what pre-endoscopy drugs do you give for…
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Task 4 – what pre-endoscopy drugs do you give for…
Non-variceal Bleed?
Suspected variceal?

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33. NICE Recommends! (4) IMPORTANT! Concerns or contra-indications?
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NICE Recommends! (4)
IMPORTANT!
Concerns or contra-indications?

34. NICE Recommends! (5) What…Never?
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NICE Recommends! (5)
What…Never?
Are there any circumstances you would?
High Rockall score?
Delay to endoscopy?
Unit policy?

35. So… Assessed varices vs. Non-variceal
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So…
Assessed varices vs. Non-variceal
Stratified risk – early discharge
Resuscitate / blood products
Drugs esp. suspected varices
Questions?

36. Case 1 27 year old male Binge of alcohol Haematemesis yesterday
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Case 1
27 year old male
Binge of alcohol
Haematemesis yesterday
All bloods, exam and obs normal
Diagnosis? Admit? Drugs? Endoscopy?

37. Case 2 88 IP on COTE – CCF Coffee ground vomit – witnessed
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Case 2
88 IP on COTE – CCF
Coffee ground vomit – witnessed
Tachy – normal BP
Bloods normal
Concerned?

38. Case 3 – 4am IP, 44yrs - # NOF after fall
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Case 3 – 4am
IP, 44yrs - # NOF after fall
Aspirin / Clopidogrel for stent 3/52 ago
Alc ++ (no stigmata CLD, bloods normal)
Haematemesis – stable BP, Tachy
Diagnosis? Severity? Drugs? Scope?

39. Case 3 – NICE Recommends! Stop all (inc NSAID) in acute situation
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Case 3 – NICE Recommends!
Stop all (inc NSAID) in acute situation
Restart aspirin ASAP following haemostasis
Secondary prevention

40. Timing of endoscopy Out of hours High risk score
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Timing of endoscopy
Out of hours
High risk score
Unstable despite resuscitation
Suspected varices

41. Case 4 Known cirrhotic / varices
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Case 4
Known cirrhotic / varices
Massive GI bleed – unstable. GCS 12/15
INR 1.9, platelets 34, Fib 0.7
Diagnosis? Treatment? Endoscopy?
Take a minute on this one….

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43. Varices! ABC Terlipressin and Tazocin MTP / blood products
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Varices!
ABC
Protect the airway
Terlipressin and Tazocin
MTP / blood products
May be little point scoping…

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Tamponade

45. Tamponade Should control bleeding in 90%
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Tamponade
Should control bleeding in 90%
Majority will rebleed within 24 hrs of removal
Bridge to endoscopy
Protect airway
Read the manual!

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47. Conclusions Make a diagnosis Stratify risk and respond
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Conclusions
Make a diagnosis
Stratify risk and respond
Start new drugs / stop (or not) others
Measure / correct clotting
Transfuse if needed
Refer when appropriate for OGD
Not as initial knee-jerk reaction!

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Questions?