The incidence of gastrointestinal hemorrhage ranges from 50 to 150 per 100 000 population each year. Reported mortality rates range from 11% to 33% for patients admitted primarily due to GI hemorrhage or who developed it as a complication of their hospital stay respectively. Show
Rapid evaluation of the patient for evidence of hemodynamic compromise as well as risk factors for serious hemorrhage is crucial to enable early resuscitation and involvement of interventional services when indicated. General resources
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AssessmentHaemodynamic Instability
Relevance of History
Medications
Laboratory StudiesAcute bleeding may not be reflected in the FBC due to ~ 24hrs delay in fluid equilibration. Microcytic changes will only be present if the bleeding / iron deficiency has been chronic. Remember that excessive crystalloid resuscitation may result in the false lowering of the haemoglobin. BUN/Creatinine ratio also positively correlated with UGI Bleeding with ratios >30 having a LR of 7.5. Causes
Although gastro-oesophageal varices are less common, managing the underlying liver disease and the severity of bleeding may be more demanding of resources. Risk Scoring SystemsIt is increasingly recognized that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. The Glasgow Blatchford Score (GBS)
Patients with a GBS score of 0 may be suitable for discharge. Higher risk groups require in-patient endoscopy for full evaluation and therapy
ManagementGeneral Management
Fluid Resuscitation
Blood ProductsThe initial resuscitation section recommends haemostatic blood product resuscitation for unstable patients in line with massive transfusion practice in trauma - with the ratio of blood products Packed Cells : FFP : Platelets recommended to be 1:1:1. However where the patient is sufficiently stable to await the pathology results, current guidelines and evidence suggest restrictive transfusion strategies especially in patients with known or suspected variceal disease. Transfuse only for:
Also give fresh frozen plasma for INR >1.5; give platelets for thrombocytopenia (aim platelets >50 x 109/L). In the bleeding patient always remember that “cold doesn’t clot” and it is much easier to prevent hypothermia than reverse it. To maintain normothermia, avoid exposure, use a blood warmer for all products and consider a bair hugger early. Avoid acidosis and ensure adequate ionised calcium levels are maintained, ie above 1.13mmol/L by giving calcium gluconate 2.2mmol (10ml) peripherally IV over 10minutes. Other medical treatments
Variceal Bleeding InterventionsTreatment specific to suspected Variceal BleedingEach episode of active variceal haemorrhage is associated with 30 percent mortality (UTD). Variceal bleeding stops spontaneously in over 50 percent of patients, but the mortality rate approaches 70 to 80 percent in those with continued bleeding. Specific to variceal haemorrhage resuscitation is the need to avoid over-transfusion in the initial management of these patients as well as ensuring rapid consideration and correction of any coagulopathies. Medical therapy aims at reducing the portal venous pressures and so reducing bleeding. Early Vasoactive therapy should be commenced as promptly as possible on presentation of the patient who has known or suspected varices and should not be held pending confirmation of the diagnosis. Vasoactive medications have been shown to significantly decrease mortality and improve haemostasis in patients with acute variceal bleeding. (There is also some evidence to indicate their efficacy in non-variceal bleeding.) This includes:
Antibiotics are indicated in variceal bleeding eg Ceftriaxone 1g IV (this decreases mortality in patients by reducing infections during ICU admissions). More information on antibiotics can be found on eTG complete (institution or subscription access required) Endoscopy is first line in variceal disease for diagnosis and intervention with potential banding or injection and decreases the risk of rebleeding to approximately 30 percent Surgical intervention has little role in the management of varices and patients who do not respond to endoscopic therapies are best treated by Transjugular Intrahepatic Portosystemic Shunt (TIPSS). Specifically, if the location of the varices is known;
A guide to intubating the patient with a massive variceal bleed can be found here. After intubation, Balloon tamponade is an option of last resort to temporarily stop bleeding from oesophageal or gastric varices while definitive treatment is being arranged, but it is associated with serious complications including oesophageal rupture – so always remember to confirm placement of the gastric balloon before you fully inflate it. Confirmation of placement is by listening over the stomach and lungs injecting air into the stomach port, and then inflating 50 mls of air or saline and doing X-ray top confirm in the stomach. There are 3 types of tubes used for balloon tamponade. This video (EMRAP) provides an excellent overview. 1. Sengstaken-Blakemore tube - 3 ports (2 for filling the balloons with air, and 1 for gastric suction)
2. Minnesota tube – 4 ports (just a modified Sengstaken-Blakemore tube)
3. Linton-Nachlas tube – 1 port
An excellent blog entry on EMCrit here describes placement and has a downloadable pdf of a quick guide . Remember that Balloon tamponade should only be considered as an interim and dire measure pending endoscopy or where endoscopy has failed and the patient is awaiting TIPS. More information on how to attempt balloon tamponade can be found here. Long term, the administration of a nonselective beta blocker such as propranolol can also decrease the risk of rebleeding in variceal bleeders. Non-Variceal Bleeding InterventionsEndoscopy is considered the gold standard for diagnosis and intervention. Endoscopy is recommended within 24 hours of presentation for the diagnosis and treatment of active UGI bleeding and for the prevention of recurrent bleeding rather than waiting more than 24 hours. Where endoscopy is not available, some evidence suggests that the use of Somatostatin and its long-acting analogue Octreotide may be of benefit even in non-variceal upper GI bleeding. Studies have used standard dosing for Somatostatin but the Octreotide infusion, after a 50mcg bolus, to be administered at half-rate of 25mcg/hr. For patients who endoscopy has failed or is contraindicated, the options include: Interventional Angiography
Surgery
With appropriate treatment, high-risk lesions have recurrent bleeding rates of 5 to 20 percent, depending upon the endoscopic appearance of the ulcer base. The majority of patients with UGI bleeding due to peptic ulcer disease will stop bleeding spontaneously, and most will not re-bleed during hospitalisation. Also, remember to consider whether there are any modifiable predisposing risk factors for ulcer formation e.g. stopping NSAIDs / smoking / H. pylori) and treated as appropriate. Intubating the unstable GI bleederMassive GI hemorrhage presents a number of challenges during and after intubation
Steps to Maximise success1. Use your airway checklist, consider and PLAN for the worst and prep your team. 2. WEAR PPE for all staff involved - especially Goggles, Gloves and Mask! 3. Empty the Stomach (if tolerated insert an NG and put it on low wall suction – varices are not a contraindication) 4. Administer prokinetic, eg Metoclopramide 10mg IV ( “proper” prokinesis is 20 mg) or erythromycin 250mg IV 5. Intubate with patient HOB at 45deg – but if the patient vomits - > Trendelenberg to get the vomit out of the lungs 6. Have an assistant allocated to the role of suctioning on the left, and have a spare Yanker sucker setup in case the first gets blocked. 7. Preoxygenate well with good seal (if possible) but try to avoid NIV if vomiting 8. Apneic oxygenation (using continuous Nasal prong oxygenation) is a must in these patients 9. BVM gently and slowly to re-oxygenate , if needed, (6-10 breaths /min)\ 10. Use video laryngoscopy if available but have a standard laryngoscope blade ready in case of blood / fluids obscuring the camera. 11. Must Paralyze to optimize your 1st pass success. Where Suxamethonium contraindicated, Paralyze with Rocuronium 1-1.2mg/kg to minimize time to onset of action. Paralysis does not reduce the lower oesophageal tone. 12. Consider using a hemodynamically stable sedative like Ketamine 1-2mg/kg 13. No role initially for antibiotics in “chemical pneumonitis” from aspiration – but may require antibiotics (Ceftriaxone) if variceal bleed. SIRS response may require further fluid resuscitation +/-vasopressors. Recent evidence suggests that all variceal bleeds should get antibiotics. Further References and Resources
Further References and Resources
What is the nursing priority in the management of patient with active upper GI bleeding?Rapid assessment and management of airway, breathing and circulation is the initial priority.
Which goals are appropriate for a patient with upper GI bleeding?The goal of medical therapy in upper gastrointestinal (GI) bleeding (UGIB) is to correct shock and coagulation abnormalities and to stabilize the patient so that further evaluation and treatment can proceed. In addition to intravenous (IV) fluids, patients may need transfusion of packed red blood cells.
How do you manage acute upper GI bleed?Acid suppression — Patients admitted to the hospital with acute upper GI bleeding are typically treated with a proton pump inhibitor (PPI). The optimal approach to PPI administration prior to endoscopy is unclear. Options include giving an IV PPI every 12 hours or starting a continuous infusion.
What are common treatment protocols for a patient with a GI bleed?How do doctors treat GI bleeding?. inject medicines into the bleeding site.. treat the bleeding site and surrounding tissue with a heat probe, an electric current, or a laser.. close affected blood vessels with a band or clip.. |