Management of Massive Upper GI Haemorrhage

1. Ian Muir - CME
Management of Massive Upper GI
Haemorrhage
-Latest Evidence-

2. Case
•
•
•
•
52yo female with massive haematemesis
Known alcoholic with cirrhosis (Child B)
Hypotensive and tachycardic, drowsy
Initial actions?

3. Massive UGIB
• Coordination multiple consultants
-Gastroenterology
-Interventional Radiology
-General surgery
• Haemodynamically unstable pt in haemorrhagic
shock – Haematemesis or Haematochezia
• Majority (>75%) of massive GI bleed is from the upper
GI tract (Proximal to ligament of Treitz – D4)
• More common in males and in the elderly (>60)antiplatelet use/anticoagulants/co-morbidities
• Incidence 1/1000
• Mortality 5-10%

4. Etiology
Peptic ulcer disease -50%
H.pylori,NSAIDS,smokers,ETOH,steroids
• Duodenal ulcers – 28%
• Gastric Ulcers – 26%
• Gastritis – 13%
Esophageal/Gastric Varices – 12%-25% (ETOH/Hepatic)
• Esophagitis - 8%
• Mallory-Weiss – cardio-esophageal tear
• Angiodysplasia/Dieulafoy lesions
• Boerhaave’s syndrome
• Other : Stress ulcers/AVM/Malignancy/Aortoenteric fistula
• Exclusion of other sources –pulm/ENT causes - Hemoptysis
• 10% no source found

5. Management- Resuscitation
•
•
•
•
•
Supplemental O2/Keep NBM 24h
Concurrent assessment and resuscitation
Stabilization and monitoring
A,B-Almost always need endotracheal intubation
-Ongoing haematemesis and altered resp.and mental changes
-Definitive airway Mx
-Facilitation endoscopy
-Airway control/protection – Aspiration/ACS
-Technically challenging – poor visualization
additional personnel and airway adjuncts/Trendellenberg
C-2 Large bore peripheral IV cannula’s (16G or larger)
-Introducer sized central venous catheter (IJV)/PAWC
-Level 1 rapid infusor primed if required
-Invasive arterial blood pressure monitor
-Comprehensive cardiopulmonary monitoring
-Keep warm – Warm fluids and blankets – avoid hypothermia/hypoglycaemia
Early mobilization of Specialists
Timely transfer to a facility with required skills

6. Management-Resuscitation
• Medical therapy alone unlikely to achieve haemostasis
• NGT and gastric lavage not useful in risk stratification potentially
harmful, may play role in improving visualisation for endoscopy
• Consideration of additional monitoring of fluid status- dynamic
measurements –bedside USS –IVC diameter
• 1.Repletion of intravascular volume
-Prompt volume resuscitation IV crystalloids – 20ml/kg
-500ml aliquots q30mins titrated to parameters
-Aim to achieve a perfusing MAP until emergency blood avail.
-Lacks O2 carrying capacity
-No replenishment of coagulation factors
-Hemostatic resuscitation
-Avoid excessive fluid resuscitation in cirrhotic pt

7. Investigations
•
•
•
Bedside : ECG, BSL, VBG, bedside USS
Initial Laboratory tests
- FBE with differential, platelet count, Hct
-Group and cross match
-U&E ; urea and creatinine ratio -30:1
-TEG –Thromboelastography test –evaluate plt fx and Coagulation
may direct type of transfusion products required
-LFT
-Cardiac enzymes –Trop T/I – elderly pt to exclude AMI in large bleed
-Coags – INR:>1.8/PT/PTT:>60sec and fibrinogen, D-dimer
-FFP,cryoprecipitate and factor concentrate influence
results
Imaging - CXR

8. Management-Resuscitation
•
2.Blood Product Transfusion
-Evidence of volume depletion and continued bleeding
- O-neg PRBCs, (O-pos men/females >childbearing)/Crossmatched asap
-Intravascular Volume Resuscitation (MAP>60) when Hct <30%
-Optimization of O2 carrying capacity
-Clinical evidence of decreased O2 delivery – GCS, end-organ
hypoperfusion –ishaemia, increase s-lactate, decrease ScvO2
-Hb =<7g/dL or shock – PRBCs, FFP, platelets (1:1:1) – Military Lit.(Iraq)
-Restrictive transfusion associated with lower mortality
-Hb ideally > 9-10g/dL for unstable CAD/ Elderly
-Activation massive transfusion protocol
-Monitor complications massive transfusion
Ca, Mg – chelation via Na citrate
immediate transfusion reactions – Hemolytic/ABO
-Avoid hypothermia, acidosis and coagulopathy
-Avoid overtransfusion in variceal bleeding (>10g/dL) – increase portal
pressure may ppt worsening of bleeding (cirrhotic pt) even with IHD
-Rate determined by severity of hypovolaemia,tempo bleeding,and comorbidities

9. Management -Specific
•
Reversal of Coagulopathy
-INR>1.5 and platelets <50000 +/- bleeding – FFP(10ml/kg)/platelets
Attempt to get INR <3 prior to endoscopy,should not delay endoscopy
-Reversal of medical induced coagulopathy:
-Warfarin – 1st Prothrombin complex concentrates (Prothrombinex-VF)
-25-50 IU/kg
No crossmatch required/acts >rapid than FFP alone
- Discontinue Warfarin +Vit. K 5-10mg IV
- rFVIIa – expensive/thromboembolism risk
conflicting evidence in literature – routine use not recomm.
But consider in severe liver disease/refractory bleeding
despite FFP
-Dabigatran(Pradaxa) –direct thrombin inhibitor – degree of
coagulopathy obtain PT and
thrombin time –only qaulitative indication, lacks
sensitivity with therapeutic dabigatran levels
–no evidence, aggressive FFP,rFVIIa, CVVHDF

10. Management -Specific
• Rivaroxaban(Xarelto) – Xa inhibitor
- PCCs or FFP
-UFH – Acts on multiple sites clotting cascade/catalyst
clotting factors –Protamine sulphate –basic prot that
combines with heparin to form stable inactive complex
- 1mg neutralise 100IU Heparin
-Aspirin/Clopidogrel –platelets –no evidence at this stage
-Stop NSAIDS
• Weigh thrombotic risk vs continued bleeding and when
to resume medications after haemostasis achieved
(Cardiology consult if high risk for IHD/Vascular stent)

11. Management-Specific
•
Pharmacologic Therapies
-Proton Pump Inhibitors – Inhibition gastric
H+/K+ATPase /neutralization of gastric acid/Pepsin
Stabilization blood clot-Current emperic in acute UGIB
Has been the mainstay early treatment/Adjunct to endoscopy
Proposed reduction haemorrhage during endoscopy,no immediate
impact
No statistical evidence of reduction in rebleeding or the
need for surgery or mortality reduction- No benefit 100%
-Generally in non variceal bleeding
-Cost effective/Excellent safety profile – risk benefit
ratio greater in high risk pt’s – 0% harm
-Pantoprazole 8mg /infusion 8mg/hr
-Concern about the addition of PPI to longterm clopidogrel for
risk of thrombotic stroke or AMI – 50% increase with concurrent use over
longterm

12. Management-Specific
•
-Somatostatin/Octreotide/Vapreotide (analogues)
-Use is controversial/Inferior to endoscopy
-Suspected acute variceal bleeding,not routine for ulcerative bleed
-Endoscopy unavailable or contraindicated or
uncontrolled bleeding while waiting for endoscopy
-Inhibits release of GI hormones: Gastrin/CCK
motilin,secretin – reduction portal venous blood
flow secondary to splanchnic vasoconstriction
-In combination with Endoscopic sclerotherapy
-Low risk side effect profile
- Potentially reduce risk bleeding non variceal causes(Kim et al)
where endoscopy unavailable but not routine or as
adjunctive therapy to stabilize pt prior to definitive care
Little data exists in non variceal bleeds
-Cochrane review –no significant change in mortality or rebleeding
but reduce need for blood transfusion by 0.5 units
-IV bolus 25-50mcg then 20-50mcg/hr minimum of 24 hours in ICU

13. Management-Specific
• Vasopressin/Terlipressin
-Reduction of portal HTN via splanchnic and
systemic vasoconstriction
-Use is controversial/Mortality benefit in Child-Pugh C patients
shown with Terlipressin
-High rates of serious complications vasopressin (3% fatal)
-Risk similar but less severe than other vasopressor
therapy(AMI/Arrhythmias/skin necrosis/mesenteric ischaemia, cardiac arrest, systemic HTN)
-Addition of nitroglycerin may decrease side effects
but does not affect the efficacy if vasopressin
-Use may be justified in pt in extremis due to
massive UGIB and exsanguination to achieve hemostasis
-Generally use should be limited –caution in OUD bleed
-20units IV over 20 minutes then 0.2-0.4 U/min Vasopressin
- 2mg q4hly IV (1mg <40kg) Terlipressin

14. Management-Specific
• Prophylactic Antibiotics
-Patients with Cirrhosis – Bacterial inf.-20% GI bleed
-Immune dysfunction
-Translocation gut bact
- 50% develop HA infection
- Increased mortality
-May reduce risk of recurrence bleeding in variceal
bleeding/Prior or after endoscopy – 23% infection prevention
4.7% prevention death
-Cipro 400mg bid/Ceftriaxone 1g IV qid
• Tranexamic acid
-No beneficial effect above standard therapy,no role in
the treatment of acute UGIB
• H2 antagonists no benefit in acute upper GI bleed
no reduction in rebleeding

15. Management-Specific
• Prokinetics
-Erythromycin/Metclopramide
-Improves gastric visualization during endoscopy
-Shorten endoscopy time
-Reduce need for second-look endoscopy
-Consider in large bleeds with large amount
blood
in stomach
-3mg/kg IV – 30-90 minutes prior to endoscopy
-More benefit towards use of erythromycin

16. Management-Specific
• Procedural therapies
- Endoscopy
-Diagnostic and therapeutic modality of choice
-Accurate at locating bleeding site (78-95%) and predict
mortality + risk stratification about rebleeding
- Banding,clipping, sclerosant injection +/- Adren.
Ethanol and thrombin – combination methods >effective
-Co-aptive Rx – heater probe thermo-coagulation
-Early endoscopy within 4h advocated
-Pt need to be HD stable prior to endoscopy – Hct <30%
tolerated and mild to moderate anticoagulation
-Riks : Aspiration, GA, perforation, increased bleeding
systemic sclerosing agent dissemination
-More complications associated with recent AMI and very
ill patients – Apache II score >16/hypotension
-Forest classification – description of peptic ulcers

17. Management-Specific
• Balloon tamponade
-Endoscopy not available or ineffective haemostasis
despite adequate resuscitation
-Requires pt to be intubated
-Rare but potentially life saving procedure
- 3 lumen/Gastric + esophageal balloon/gastric suction port – nasal/oral @ 50cm–inflate <40-50mmHg
- Confirm correct placement prior to inflation
-Temporary rescue device – stops bleeding 80%
-Associated with high risk re-bleeding on deflation
-Lethal complications of esophageal necrosis and
rupture (14% major compl/3% fatal),asphyxiation
-Senstagen-Blakemore, Minnesota tube,Linton (>effective in
Gastric variceal bleeding)
-Transfer to facility with definitive care

19. Management-Specific
•
Additional Procedural Therapies
-Angiography – Nonvariceal/Failed Endoscopy/1% of pt
- Failed medical management
- Endoscopy unavailable/High risk surgery
- Detect bleeds of 0.5ml/min with 100% sens.
- Transcatheter embolization Gelfoam/vasopressin
-Radionuclide imaging – Localization/identification source
indolent/elusive (Nuclear isotope-tagged RBC scan)
- Upper GI Barium studies contraindicated
- Wireless capsule endoscopy in ED on presentation
esophageal capsule- 20minutes recording time
- Colonoscopy – negative gastroscopy/hematochezia
-Surgery – perforation or peritonism/precipitation massive bleed
during endoscopy (>5units first 4-6h)
-Aorta-enteric fistula (Aortic stent/graft)
-Less effective in variceal bleeding
Rx-TIPS Transjugular Intrahepatic Portosystemic Shunt (23%
mortality)

20. Disposition
• ICU – Hct<30%, syst BP<100, Hx cirrhosis/ascites
vomiting frank red blood
• Manage complications associated with alcoholism
and hepatic encephalopathy
• Early involvement sub specialities
• Interfacility transfer if required
• Risk stratification: Rockall/Modified Blatchford
AIMS65
• Long term : Beta blocker therapy in pt with
varices may prevent initial bleed
and rebleed
H.pylori eradication therapy

21. Questions?
• References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in
upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Jul 7;7:CD005415. Review. PubMed PMID: 20614440.
Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1995;
90:206.
2 Crooks C, Card T, West J. Reductions in 28-day mortality following hospital admission for upper gastrointestinal hemorrhage. Gastroenterology
2011; 141:62.
3 Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology 1988;
95:1569.
4 Zuckerman GR, Trellis DR, Sherman TM, Clouse RE. An objective measure of stool color for differentiating upper from lower gastrointestinal
bleeding. Dig Dis Sci 1995; 40:1614.
5 Wilcox CM, Alexander LN, Cotsonis G. A prospective characterization of upper gastrointestinal hemorrhage presenting with hematochezia. Am J
Gastroenterol 1997; 92:231.
6 Jutabha R, Jensen DM. Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Med Clin North Am 1996; 80:1035
7 Boonpongmanee S, Fleischer DE, Pezzullo JC, et al. The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated. Gastrointest
Endosc 2004; 59:788.
8 Enestvedt BK, Gralnek IM, Mattek N, et al. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a
large multicenter consortium. Gastrointest Endosc 2008; 67:422.
9 Balderas V, Bhore R, Lara LF, et al. The hematocrit level in upper gastrointestinal hemorrhage: safety of endoscopy and outcomes. Am J Med 2011;
124:970
10 Loperfido S, Baldo V, Piovesana E, et al. Changing trends in acute upper-GI bleeding: a population-based study. Gastrointest Endosc 2009; 70:212.
11 Hunt RH, Malfertheiner P, Yeomans ND, et al. Critical issues in the pathophysiology and management of peptic ulcer disease. Eur J Gastroenterol
Hepatol 1995; 7:685.
12 Hallas J, Lauritsen J, Villadsen HD, Gram LF. Nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding, identifying high-risk groups
by excess risk estimates. Scand J Gastroenterol 1995; 30:438.
Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper
gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD002907. Review. PubMed PMID: 20824832.