Summary:  Jeff Duncan

Editor:  Anastasia Volovets

 

With Dr Anastasia Volovets, Gastroenterologist and Hepatologist, Royal Prince Alfred Hospital, Sydney, Australia

 

James talks to Anastasia Volovets about upper GI bleeding.

Dr Anastasia Volovets is a consultant gastroenterologist and hepatologist. After completing her advanced training at Royal Prince Alfred Hospital, she took off for the green pastures of Edinburgh in Scotland to complete a fellowship in advanced liver disease and liver transplantation. On return she did some more liver transplantology as a consultant before settling into a part time staff specialist duties at RPA as well as some private practice locally.

Anastasia loves teaching patients, nurses, medical students and other doctors almost as much as she loves the liver. She is currently involved in developing a state wide curriculum on gastrostomy feeding in her spare time and can often be found wondering the hospital with a cup of coffee and a toxicology textbook.

 

Case – You are a junior doctor working after hours and you are called to review a gentleman admitted with alcohol withdrawal who has just vomited up coffee ground vomitus.

1. Initial Assessment

  • Recognition of the severity of illness – haemodynamically unstable? Shocked? Does he need ICU review?
  • Is there any frank, bright red haematemesis? – warrants immediate activation of hospital rapid response call
  • Coffee ground vomit doesn’t always signify an upper GI bleed. It may represent gastric stasis secondary to a variety of conditions, especially in the absence of a haemoglobin drop
  • Melaena is diarrhoeagenic – the presence of dark/black well-formed stools doesn’t suggest a recent upper GI haemorrhage; think iron supplements instead

2. Assessment approach by the bedside

  • History
    • Is there a previous history of melaena (black, tarry, liquid, pungent stools) or haematemesis?
    • Is there a history of GORD?
    • Has there been a history of syncope or black-outs recently?
    • History of liver disease or cirrhosis?
    • Risk factors for liver disease – alcohol, longstanding Hepatitis B/C, chronic autoimmune hepatitis, previous pancreatic surgery
    • Medication history – particularly NSAIDs, PPIs, steroids, bisphosphonates
    • Previous endoscopy or diagnosis of GI ulcer?
    • Previous history of abdominal aortic aneurysm with endovascular repair – think aorto-enteric fistula
  • Examination
    • Broad approach required (including assessment of volume status):
      • Assessment of the observations is paramount
      • Postural blood pressure (if haemodynamically stable – useful in assessing volume status)
      • Per rectum examination
      • GI examination (specifically for signs of anaemia or chronic liver disease)

3. Investigations

  • Bloods – FBC (specifically Hb), UEC (particularly Urea – gross elevation in excess of elevations in Creatinine suggestive of GI haemorrhage), LFTs
  • VBG – lactate, base excess (if patient quite unwell), can get an urgent Hb
  • Group and Hold

4. What are the common causes of upper GI bleeding?

  • Variceal – Patients with chronic liver disease with dilated veins in oesophagus or stomach
  • Non-variceal
    • Peptic ulcer disease – gastric or duodenal ulcer
    • Upper GI malignancy – oesophageal, gastric, duodenal or small bowel tumours such as GIST, Carcinoid, Lymphoma etc.
    • Aberrant blood vessels e.g. Dieulafoys lesion

5. Management (short term)

  • Urgent IV Access with two large bore cannulae
  • IV fluids
  • Oxygen if required
  • Blood transfusion – Hb target for resuscitation in cirrhotic patients is 70 mg/dL in consultation with anaesthetics/gastroenterology
  • Platelets – if significantly thrombocytopaenia (<50), the patient will probably require platelet transfusion
    • Platelet transfusions may also be required in patients on anti-platelet therapy for cardiovascular disease even with a normal platelet count such as Ticagrelor, Aspirin, Clopidogrel
  • Warfarin reversal may be required urgently if unstable, however use of Fresh Frozen Plasma or Prothrombinex requires discussion with gastroenterology prior beforehand if the patient is stable
  • Antibiotics – for prevention of Spontaneous Bacterial Peritonitis (SBP) – Piperacillin / Tazobactam commonly used
  • For variceal bleeding:
    • Terlipressin – survival improvement data exists, but note the increased risk of complications such as pulmonary oedema
    • Octreotide – may be required to reduce portal pressures
  • IDC – if required, for strict input/output monitoring
  • Arterial lines / central lines – may be required
  • NGT almost never required – particularly if variceal bleeding is suspected
  • IV Proton Pump Inhibitor (PPI) prior to endoscopy
    • Controversial topic; and largely depends on gastroenterologist preference and time line to endoscopy
    • If endoscopy is being delayed as the patient is stable, err on side of caution and administer a PPI

6. Management (post-endoscopy)

  • Depends on what is found
    • Ulcer with no high-risk stigmata – discharge on PPI and antibiotics if H. Pylori positive
    • High-risk ulcer
      • Active bleeding, visualised blood vessel, fresh clot
      • Usually treated endoscopically with adrenaline injections, cauterised, clipped etc
      • Requires 72 hours IV PPI as a continuous infusion
      • Then 4-6/52 oral PPI with follow-up endoscopy
    • Varices
      • IV antibiotics for 72 hours
      • Follow-up care with repeat endoscopies and banding of varices to eradication
  • Patients with pre-existing anti-platelet therapy
    • JMO Role – know the specific reason why the patient is on their anti-platelet therapy in order to appreciate the importance of restarting it (if at all)
    • Low-risk – restart immediately
    • High risk – withhold for 7-10 days, depending on liaison with cardiology and gastroenterology
    • There are significant risks to the patient of not restarting anti-platelets promptly as patients have cardiac morbidity in the months post-UGI bleed – cardiology and gastroenterology discussion and medication reconciliation is really important prior to discharge

Take home messages

  • Unstable patients will require resuscitation and management
  • Stable patients
    • Often require less resuscitation or need for anticoagulation reversal
    • Discussion with gastroenterology early is paramount
  • Medication reconciliation is important, particularly at the time of discharge

 

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Podcast

Upper GI bleeding