UPPER GI HAEMORRHAGE

Symptoms and signs

• Coffee-ground vomit
• dark brown, denatured blood in vomit
• Haematemesis
• bright red or clotted blood in vomit
• Melaena
• black, tarry, smelly stool containing digested blood
• Postural dizziness or fainting
• Evidence of severe bleeding defined as:
• clammy skin
• shock with tachycardia (heart rate >100 beats/min)
• hypotension (systolic BP <100 mmHg)
• postural hypotension in patient who is not clinically shocked
• Evidence of anaemia
• Features of precipitating disease
• jaundice, stigmata of liver disease
• Features of bleeding disorder (petechiae)
• Buccal or facial telangiectasia
• Bright red rectal bleeding in the absence of hypotension is likely from lower GI tract

Previous history

• Enquire about:
• peptic ulceration
• previous bleeds
• liver disease
• family history of bleeding
• ulcerogenic medication/anticoagulants
• alcohol
• weight loss

Investigations

All

• FBC
• U&E

Non-severe bleeding

• Group and save (non-urgent)

Severe bleeding

• INR
• LFTs
• Crossmatch (4 units)
• notify blood transfusion laboratory of clinical problem and degree of urgency

After undertaking risk assessment, choose one pathway below

• Send to observation unit

Observations

2-hrly

• Heart rate
• BP: lying and standing at 3 min

Investigations

• FBC
• U&E
• Group and save (non-urgent)
• Repeat FBC and U&E 4 hr after admission to CDU

Treatment

• None, unless specific cause or increase in severity identified

Review after 6 hr

• All normal?
• Safe for discharge?
• If still worried, repeat assessment of risk

Admission criteria

• Glasgow Blatchford score ≥1
• Further episode of GI bleed
• Haemodynamic instability
• Abnormal blood results

Criteria for discharge and outpatient OGD

• Glasgow Blatchford score 0
• No co-morbidities requiring acute admission
• Patient information pack provided to patient
• Request outpatient OGD
• Give patient copy of discharge letter

• Baseline observations
• Order upper GI endoscopy within 24 hr/next available endoscopy list
• Wide bore IV access
• Allow food and drink until 4 hr before endoscopy
• No treatment necessary before endoscopy
• Send patient to acute GI unit

Investigations

• FBC
• U&E
• INR
• LFTs
• Crossmatch (4 units)
• notify blood transfusion laboratory of clinical problem and degree of urgency

Subsequent management

• Continue observations until outcome of upper GI endoscopy is known
• Follow advice on the endoscopy report

Preferred eradication regimen for Helicobacter pylori

• Give for 7 days
• absolute compliance with regimen essential for an eradication rate of 90%
• if ulcer large, or complicated by haemorrhage or perforation, continue omeprazole for a further 21 days

Not allergic to penicillin

• Omeprazole 20 mg oral 12-hrly
• Amoxicillin 1 g oral 12-hrly
• Metronidazole 400 mg oral 12-hrly

Patients allergic to penicillin

• Omeprazole 20 mg oral 12hrly
• Clarithromycin 250 mg oral 12hrly
• Metronidazole 400 mg oral 12hrly
• Simvastatin contraindicated with clarithromycin 

After eradication of Helicobacter pylori

• If NSAID therapy reintroduced, continue omeprazole 20 mg oral daily for as long as NSAID required
• If neoplasm identified, refer to upper GI cancer team

Patients who rebleed

• If an otherwise stable patient who is potentially referable for surgery rebleeds, request urgent endoscopy
• discuss with on-call surgical team

 Indications for surgical intervention

• Exsanguinating haemorrhage
• too fast to replace
• Failed endoscopic therapy
• Major rebleed after successful endoscopic therapy
• In special situations, a major bleed may warrant early surgery
• e.g. patients with rare blood group or patients refusing blood transfusion
• Once agreed with surgical team, transfer high-risk patients to surgery

Monitor

• 4-hrly heart rate and BP
• Observe vomit for blood content and stool chart for melaena
• Daily Hb until it is stable (not falling)
• In patients with severe bleeding, urine output
• aim for >30 mL/hr

Discharge and follow-up

• Discharge when stable

H. pylori positive duodenal ulcer

• Ask GP to arrange faecal antigen testing for H pylori >4 weeks after completing eradication therapy

If H.pylori positive gastric ulcer

• Ask GP to arrange:
• faecal antigen testing for H pylori >4 weeks after completion of eradication therapy
• repeat upper GI endoscopy to check healing 6–8 weeks following discharge
• If Hb still <100 g/L, start ferrous sulphate 200 mg oral 8-hrly

Non-severe bleeding with transient pathology (e.g. Mallory–Weiss tear, acute erosion)

• Discharge promptly after endoscopy with no follow-up

Non-severe bleeding and ulcer-related disease

• Discharge young stable patients (aged <45-yrs) promptly after endoscopy
• Discharge older patients (aged >45-yrs) when their condition is stable

Severe bleeding and ulcer-related disease

• Discharge when condition and Hb stable

Neoplasia

• Discuss further investigation and treatment with upper GI cancer team

Investigations

• FBC
• U&E
• INR
• LFTs
• Crossmatch (4 units)
• notify blood transfusion laboratory of clinical problem and degree of urgency

Replace fluid loss and restore BP

Logistics

• Insert 2 large bore (14–16 G) venous cannulae
• In patients with significant cardiac disease, consider CVP line to guide IV fluid replacement
• If not already an inpatient, admit
• Keep patient nil-by-mouth

Treatment

• Stop antihypertensives, diuretics, NSAIDs, anticoagulants
• Infuse compound sodium lactate (Hartmann’s) solution or sodium chloride 0.9% 1–2 L over 30–120 min to achieve systolic BP >100 mmHg
• Transfuse as soon as blood available. See Blood and blood products guidelines
• prefer packed cells
• if 50% of total blood volume loss in 3 hr, follow Massive haemorrhage protocol with blood bank to obtain blood products rapidly

Other initial management

• Once resuscitation has begun, give omeprazole 80 mg by IV infusion over 40–60 min
• then by continuous IV infusion of 40 mg in 100 mL sodium chloride 0.9% at 20 mL/hr (8 mg/hr) for 72 hr
• Arrange upper GI endoscopy
• contact gastroenterology

Surgical intervention

• After preliminary resuscitation, discuss all patients with severe non-variceal bleeding with on-call surgical team
• if appropriate, transfer patient to general surgical care for further management
• If doubt about realistic possibility of surgery, duty surgeon and duty physician to review patient in consultation
• If any difficulties are encountered with this policy, inform on-call consultant physician
• contact a senior gastroenterologist only if on-call team unable to resolve the clinical management problem satisfactorily with duty surgical team
• Indications for surgical intervention or interventional radiology under surgical care are:
• exsanguinating haemorrhage (too fast to replace or requiring >4 units of blood to restore blood pressure)
• failed medical therapy
• special situation (e.g. patients with rare blood group or refusing blood transfusions)

Subsequent management

• Continue observations until know outcome of upper GI endoscopy
• Follow advice on the endoscopy report

Preferred eradication regimen for Helicobacter pylori

• Give for 7 days
• absolute compliance with regimen essential for an eradication rate of 90%
• if ulcer large, or complicated by haemorrhage or perforation, continue omeprazole for a further 21 days

Not allergic to penicillin

• Omeprazole 20 mg oral 12-hrly
• Amoxicillin 1 g oral 12-hrly
• Metronidazole 400 mg oral 12-hrly

Patients allergic to penicillin

• Omeprazole 20 mg oral 12hrly
• Clarithromycin 250 mg oral 12hrly
• Metronidazole 400 mg oral 12hrly
• Simvastatin contraindicated with clarithromycin

After eradication of Helicobacter pylori

• If NSAID therapy reintroduced, continue omeprazole 20 mg oral daily for as long as NSAID required
• If neoplasm identified, refer to upper GI cancer team

Patients who rebleed

• If an otherwise stable patient who is potentially referable for surgery rebleeds, request urgent endoscopy
• discuss with on-call surgical team

Indications for surgical intervention

• Exsanguinating haemorrhage
• too fast to replace
• Failed endoscopic therapy
• Major rebleed after successful endoscopic therapy
• In special situations, a major bleed may warrant early surgery
• e.g. patients with rare blood group or patients refusing blood transfusion
• Once agreed with surgical team, transfer high-risk patients to surgery

Monitor

• 4-hrly heart rate and BP
• Observe vomit for blood content and stool chart for melaena
• Daily Hb until it is stable (not falling)
• In patients with severe bleeding, urine output
• aim for >30 mL/hr

Discharge and follow-up

• Discharge when stable

H.pylori positive duodenal ulcer

• Ask GP to arrange faecal antigen testing for H pylori >4 weeks after completing eradication therapy

If H.pylori positive gastric ulcer

• Ask GP to arrange:
• faecal antigen testing for H pylori >4 weeks after completion of eradication therapy
• repeat upper GI endoscopy to check healing 6–8 weeks following discharge
• If Hb still <100 g/L, start ferrous sulphate 200 mg oral 8-hrly

Non-severe bleeding with transient pathology (e.g. Mallory–Weiss tear, acute erosion)

• Discharge promptly after endoscopy with no follow-up

Non-severe bleeding and ulcer-related disease

• Discharge young stable patients (aged <45-yrs) promptly after endoscopy
• Discharge older patients (aged >45-yrs) when their condition is stable

Severe bleeding and ulcer-related disease

• Discharge when condition and Hb stable

Neoplasia

• Discuss further investigation and treatment with upper GI cancer team

Investigations

• FBC
• U&E
• INR
• LFTs
• Crossmatch (4 units)
• notify blood transfusion laboratory of clinical problem and degree of urgency

Fluid and controlling haemorrhage

• Haemorrhage from oesophageal varices is always life-threatening

Logistics

• Insert 2 large bore (14–16 G) IV cannulae, 1 in each antecubital fossa
• In patients with significant cardiovascular disease, a CVP line is advisable

Treatment

• Initially infuse sodium chloride 0.9% 1 L over 2–4 hr:
• if Hb <100 g/L, transfuse 1 unit of blood for every 10 g/L <100 g/L. See Blood and blood products guideline
• Correct raised INR with fresh frozen plasma
• prothrombin complex concentrate recommended for major bleeding associated with warfarin-see BLEEDING/OVER-ANTICOAGULATION: WARFARIN guideline
• Continue fluid replacement but avoid rapid fluid replacement as it increases risk of rebleeding
• Aim to restore heart rate <100 beats/min, systolic BP >80 mmHg and Hb ≥100 g/L
• If haemorrhage still not controlled, discuss with gastroenterology team

Other initial management

• Contact gastroenterology to arrange upper GI endoscopy
• Whilst awaiting endoscopy, give terlipressin 2 mg IV bolus
• then 1 mg 6-hrly, duration directed by endoscopist

Antimicrobials

• Always obtain blood culture before giving an antimicrobial
• see Collection of blood culture specimens guideline
• If septic, see Sepsis guideline

Penicillin Allergy

• True penicillin allergy is rare
• Ask the patient and record what happened when they were given penicillin
• If any doubt about whether patient is truly allergic to penicillin, seek advice from a microbiologist or consultant in infectious diseases

Infection Control alerts

• Check for IC alert
• if IC alert not available, check previous 12 months of microbiology reports
• If MRSA present, treat as tagged for MRSA. See MRSA management
• If ESBL, MGNB, CARB present, treat as tagged for ESBL. See ESBL/MGNB/CARB management

Not penicillin allergic

• Give co-amoxiclav 625 mg oral or if nil-by-mouth, 1.2 g IV 8-hrly for 3 days

Penicillin allergic patients

• Give aztreonam 1 g IV 8-hrly and metronidazole oral 400 mg 8-hrly
• if nil-by-mouth, 500 mg IV by infusion 8-hrly for 3 days

Previously MRSA colonised

• Add vancomycin IV by infusion. See Vancomycin guideline

Encephalopathy

• In patients with grade 4 encephalopathy, see Acute liver failure guideline
• Discuss endotracheal intubation with gastroenterology
• if decided to intubate, contact critical care team
• If not already inpatient, admit
• Contact gastroenterology team for advice on further management

Monitor

• 4-hrly heart rate and BP
• Observe vomit for blood content and stool chart for melaena
• Daily Hb until it is stable (not falling)
• In patients with severe bleeding, urine output
• aim for >30 mL/hr

• Discharge when stable
• Start propranolol 40 mg oral 12-hrly, unless contraindicated
• prophylaxis for further variceal bleeding
• Refer to Liver specialist for follow-up