Upper Gastrointestinal Bleeding

Introduction: Haematemesis & Melaena

Upper gastrointestinal bleeding (UGIB) is a common medical emergency with significant morbidity and mortality. It commonly presents with haematemesis (vomiting of blood or coffee ground-like material) and/or melaena (black, tarry stools). In 5–10% of patients with severe UGIB, it may present as haematochezia (see below).

Over the last two decades there have been advances in drug therapy for peptic ulcer disease and varices, improvements in endoscopic techniques, interventional radiology and surgical management, in addition to advances in resuscitation and supportive care. Despite these advances, mortality for patients presenting with UGIB remains around 6–11%, with approximately 6–8% requiring emergency surgery.

Patients with UGIB are increasingly elderly and have more comorbidity than in the past, which helps to explain the lack of apparent improvement in mortality. Patients now rarely die of exsanguination, but more commonly of multiple organ failure secondary to pre-existing comorbidities.

Epidemiology, Aetiology and Differential Diagnosis

Peptic ulceration remains the most common cause of UGIB despite the recognition and treatment of Helicobacter pylori infection as a primary cause of peptic ulcer disease, accounting for between 35% and 50% of all cases. This represents a significant reduction compared to around 66% two decades ago. The pathogenesis of peptic ulcer disease is complex but is closely related to a variety of risk factors, including Helicobacter pylori infection, use of non-steroidal anti-inflammatory drugs (NSAIDs), smoking and alcohol use.

Gastroduodenal erosions and oesophagitis make up a further 15% of cases. Oesophagogastric varices, resulting from portal hypertension, are the source of up to 10% of episodes of UGIB. Mallory-Weiss tears, the result of repeated vomiting, account for 5–15% of cases of UGIB and usually do not require specific treatment. The remaining causes (all <1%) include vascular lesions such as angiodysplasia, Dieulafoy’s lesion and aortoenteric fistula.

Prevention

The development of peptic ulcer disease is closely related to management of the risk factors. The effective identification and eradication of H. pylori has led to a significant reduction in the incidence of peptic ulcer disease as the cause of UGIB.

There is little doubt that restricting the prescription of NSAIDs in the elderly (the highest risk group for development of UGIB from NSAIDs, and the age group with the highest risk of mortality from UGIB) would prevent a significant number of episodes of UGIB. This is particularly relevant to emergency medicine practice, where NSAIDs are frequently prescribed as analgesia for musculoskeletal conditions. Care should be taken to prescribe the safest drugs (ibuprofen has the lowest risk profile) for the shortest possible time at the lowest effective dose.

Definitions

1. Upper gastrointestinal bleeding is defined as any bleeding within the gastrointestinal (GI) tract proximal to the ligament of Treitz. Any bleeding arising distal to that is a lower GI bleed.
2. Haematemesis is the vomiting of bright red blood. ‘Coffee-ground vomiting’ is the vomiting of digested blood clot.
3. Melaena is the passage of black, tarry stools as a result of bacterial degradation of haemoglobin within the gut. Melaena usually represents a source of UGIB, but it can rarely occur due to a lower gastrointestinal source of bleeding.
4. Haematochezia is the passage of bright red blood per rectum, and in the context of UGIB represents a briskly bleeding source of haemorrhage.

Melaena of itself is not associated with poorer outcomes in UGIB, but haematochezia is associated with a three times higher risk of death.

Clinical Features

It is usually necessary to determine whether the blood loss is from a gastrointestinal source. Blood from the nose or oropharynx can be swallowed, resulting in haematemesis and/or melaena. If bleeding is thought to be from the upper GI tract, then a number of diagnoses need to be considered (see below).

Some historical clues and caveats must be considered:

• A history of epigastric pain or dyspepsia suggests peptic ulcer disease. However, peptic ulcer disease may be painless, particularly in the elderly, and particularly in those taking NSAIDs and steroids.
• A positive history of gastric or duodenal ulcer disease or reflux oesophagitis is associated with an approximately 50% chance of finding the same diagnosis at endoscopy.
• The risk o UGIB in patients taking NSAIDs is double that of patients not taking NSAIDs.
• The classic history of nausea and repeated vomiting prior to bleeding occurs in approximately one-third of cases of Mallory-Weiss tear.

• UGIB with a history of alcohol abuse and the stigmata of portal hypertension is suggestive of varices. However, up to 40% of patients with cirrhosis who present with GI bleeding are bleeding from causes other than varices (commonly from gastric erosions).
• Conditions associated with stress ulcers include burns, major trauma, head injury, sepsis and hypotension.
• Patients with chronic renal failure have a high incidence of angiodysplasia, peptic ulcer disease and oesophagitis.
• A history of aortic surgery and gastrointestinal bleeding should alert the clinician to the possibility of an aortenteric fistula, even if the initial bleeding episode is not significant (the first bleed is often the so-called ‘herald bleed’).
• Clinical evidence of a coagulopathy should be sought, as this will influence subsequent investigation, treatment and prognosis.
• A rectal examination is essential. As previously described, stool color has prognostic significance. Testing for occult blood further increases the sensitivity of this examination, as kits such as the Hematest are able to detect as little as 6 mg of haemoglobin per gram of stool. A positive test is dependent on the time of onset of bleeding in relation to gastrointestinal transit time. False positives may be produced by certain bacterial and vegetable preroxidases, such as bananas and horseradish. False negatives may result from ferrous salts.

Clues to the speed or acuity of blood loss include:

• The most likely diagnosis: Varices produce large amounts of dark (venous) blood; aortoenteric fistulate produce massive bright red haematemesis and haematochezia, with profound circulatory collapse.
• Signs of haemodynamic instability and response to initial resuscitation: if there is a poor response there is likely to be significant haemorrhage.
• The character of the vomitus: Ongoing haematemesis is associated with large blood loss; ‘coffe-ground’ altered vomiting or clear fluid is often associated with a slower rate of bleeding.
• The color of the stool.
• The nasogastric aspirate if a tube is already in the stomach (commonly retirement home residents receiving enteral nutrition). Note that the practice of inserting a naso gastric tube in the emergency department (ED) to assess the aspirate is no longer recommended.

The key message is that if there is haemodynamic instability or other evidence of significant ongoing UGIB, fluid resuscitation should continue but arrangements should be made to expedite emergency upper gastrointestinal endoscopy. The accuracy of diagnosis is not important at this stage, but the identification of major ongoing bleeding is.

Clinical Investigation

1. Blood Tests

At the time of insertion of two widebore (>16 G) intravenous cannulae, blood should be drawn for full blood count, coagulation studies (INR/PT, APTT and fibrinogen), electrolytes, urea, creatinine, glucose level, liver function tests and urgent cross-matching.

The initial haemoglobin is of limited value as 24–48 hours are required for the intravascular volume to equilibrate. Thrombocytopenia and leukocytosis are associated with increasing morbidity and mortality.

UGIB may also result in an elevation of the urea level (relative to the creatinine), as there is a combination of an increased protein load in the gut and intravascular hypovolaemia. Blood should be taken for blood gas analysis to assess acid-base balance in those with significant bleeds. Similarly, a serum lactate level can help to identify those with clinically occult hypoperfusion who are at high risk of significant haemorrhage.

2. Imaging

A chest X-ray may be indicated where aspiration is suspected, in the elderly, or in patients with cardiopulmonary comorbidities. It should also be performed if perforation is suspected; however, perforation associated with significant UGIB is very rare.

3. Endoscopy

Although clinical and historical features can point towards the most likely diagnosis, they are not specific. There is no empirical therapy that effectively treats all causes of UGIB. As a result, a specific endoscopic diagnosis needs to be made. Exceptions may include those with a classic history suggestive of a Mallory-Weiss tear with no ongoing UGIB symptoms and stable haemoglobin and haemodynamic status, and the very elderly with major comorbidity and poor health status.

Most centers rely on endoscopy to:

• provide information on the source of bleeding with a high degree of specificity (90–95%);
• allow prediction of the likelihood of rebleeding and mortality, according to the nature and location of the lesion and stigmata of recent haemorrhage. These factors help in deciding the level of patient monitoring or whether they may be treated as an outpatient;
• provide therapy. Endoscopy facilitates haemostasis through sclerotherapy, coagulation techniques and banding of varices, and allows histological or microbiological diagnosis. In high-risk peptic ulcers, endoscopic therapy has been shown to decrease rebleeding by 75% and mortality by 40%;
• diagnose with safety is further maximized if endoscopy is delayed until the patient is haemodynamically stable and the airway patent and protected.

The sensitivity of endoscopy is optimized if performed within 12–24 hours of presentation. Urgent endoscopy should be performed in patients with active or recurrent bleeding, bright red blood on haematemesis, large bleeds (>2 units of blood required), and when variceal bleeding is suspected. Endoscopic visualization of the mucosa is enhanced by giving a single bolus of 250 mg intravenous erythromycin to promote gastric emptying 30–90 minutes before endoscopy — this should be given in the ED if an early endoscopy is warranted.

Early endoscopy facilitates management and results in earlier discharge.

Treatment

Oxygen should be administered to all patients. Massive ongoing bleeding may compromise the airway to the extent that endotracheal intubation may be required to secure and protect the airway. Intubation in these circumstances can be both difficult and hazardous, and high-volume effective suction is essential. The extent of bleeding is often underestimated, and under these conditions doses of induction agents should be dramatically reduced from normal levels.

The intravascular volume should then be optimized. The presence of shock (in most studies this was defined as a systolic blood pressure <100 mmHg) places the patient at high risk for rebleeding, requirement for surgery and death.

Note that in the elderly, patients with autonomic neuropathies (frequently found in diabetics) and those taking β-blockers or calcium channel antagonists, vital signs, including postural hypotension, may not be a reliable indicator of the degree of blood loss. Propranolol is a commonly used (and effective) prophylaxis for the prevention of variceal bleeding in cirrhotic patients, and this may blunt the haemodynamic responses of patients with acute massive variceal bleeding.

Intravacular volume should initially be replaced with isotonic crystalloid (saline or Hartmann’s) or colloid. There is no evidence of superiority for either class of intravenous fluid in UGIB at this time.

Blood should be given promptly if there is a significant risk of bleeding, and in those patients with comorbidities making them unable to tolerate periods of anaemia (e.g. chronic obstructive pulmonary disease). Aggressive resuscitation with early blood transfusion is indicated in the elderly. However, overhydration of patients with suspected varices should be avoided, as raising the portal venous pressure will cause further bleeding.

1. Monitoring

Continuous ECG monitoring, non-invasive blood pressure monitoring and pulse oximetry should be instituted, with frequent clinical reassessment. Urine output should also be measured. Invasive arterial and central venous pressure monitoring may be necessary in massive bleeds, intubated patients and those with comorbidities.

2. Coagulation

Those needing blood often require infusions of fresh frozen plasma and platelets, and these blood products should be requested early.

Fresh frozen plasma should be given when the prothrombin time is 3 seconds greater than the control, or when large transfusions are required. In all patients requiring massive transfusion, attempts should be made to avoid hypothermia by using blood warmers, heating blankets and overhead heater.

3. Endoscopy

Although endoscopy is diagnostic for UGIB, it can also be therapeutic in the majority of cases and should be performed within 24 hours of admission in all cases. It must be available 24 hours per day and should be carried out without delay when patients remain unstable despite initial fluid and blood product resuscitation. Although many guidelines stress the need for ‘hemodynamic stability’ prior to endoscopy, in cases where this is difficult to achieve, consideration must be given to achieving haemostasis by endoscopic means as part of the ongoing resuscitation process.