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Managing acute upper GI bleeding, preventing recurrences

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ABSTRACTAcute upper gastrointestinal (GI) bleeding is common and potentially life-threatening and needs a prompt assessment and aggressive medical management. All patients need to undergo endoscopy to diagnose, assess, and possibly treat any underlying lesion. In addition, patients found to have bleeding ulcers should receive a proton pump inhibitor, the dosage and duration of treatment depending on the endoscopic findings and clinical factors.

KEY POINTS

  • The first priority is to ensure that the patient is hemodynamically stable, which often requires admission to the intensive care unit for monitoring and fluid resuscitation.
  • Peptic ulcers account for most cases of upper GI bleeding, but bleeding from varices has a much higher case-fatality rate and always demands aggressive treatment.
  • Patients with ulcer disease should be tested and treated for Helicobacter pylori infection.
  • Patients with a history of bleeding ulcers who need long-term treatment with aspirin or a nonsteroidal anti-inflammatory drug should also be prescribed a proton pump inhibitor.


 

References

Upper gastrointestinal (GI) bleeding is common, costly, and potentially life-threatening. It must be managed promptly and appropriately to prevent adverse outcomes.

More people are admitted to the hospital for upper GI bleeding than for congestive heart failure or deep vein thrombosis. In the United States, the annual rate of hospitalization for upper GI bleeding is estimated to be 165 per 100,000—more than 300,000 hospitalizations per year, at a cost of $2.5 billion.1,2

Furthermore, despite advances in therapy, the case-fatality rate has remained unchanged at 7% to 10%.3 This may be because today’s patients are older and have more comorbidities than those in the past.4

CAUSES OF UPPER GI BLEEDING

Peptic ulcers account for about 60% of severe cases of upper GI bleeding,5 and they are the focus of this paper. Fortunately, up to 80% of bleeding ulcers stop bleeding spontaneously without any intervention.6

Gastroduodenal erosions account for about 12%.3

Varices due to cirrhosis are less common but more dangerous. Variceal bleeding accounts for a relatively small percentage (6%) of upper GI bleeding, but the mortality rate from a single episode of variceal bleeding is 30%, and 60% to 70% of patients die within 1 year, mostly of underlying liver disease.

Less frequent causes include Mallory-Weiss tears, erosive duodenitis, Dieulafoy ulcer (a type of vascular malformation), other vascular lesions, neoplasms, aortoenteric fistula, gastric antral vascular ectasia, and prolapse gastropathy.5

HEMATEMESIS AND MELENA

The most common presenting signs of acute upper GI bleeding are hematemesis (vomiting of blood), “coffee grounds” emesis, and melena (tarry black stools). About 30% of patients with bleeding ulcers present with hematemesis, 20% with melena, and 50% with both.7

Hematochezia (red blood in the stool) usually suggests a lower GI source of bleeding, since blood from an upper source turns black and tarry as it passes through the gut, producing melena. However, up to 5% of patients with bleeding ulcers have hematochezia,7 and it indicates heavy bleeding: bleeding of approximately 1,000 mL into the upper GI tract is needed to cause hematochezia, whereas only 50 to 100 mL is needed to cause melena.8,9 Hematochezia with signs and symptoms of hemodynamic compromise such as syncope, postural hypotension, tachycardia, and shock should therefore direct one’s attention to an upper GI source of bleeding.

Nonspecific features include nausea, vomiting, epigastric pain, vasovagal phenomena, and syncope.

WHAT IS THE PATIENT’S RISK?

An assessment of clinical severity is the first critical task, as it helps in planning treatment. Advanced age, multiple comorbidities, and hemodynamic instability call for aggressive treatment. Apart from this simple clinical rule, scoring systems have been developed.

The Rockall scoring system, the most widely used, gives estimates of the risks of recurrent bleeding and death. It is based on the three clinical factors mentioned above and on two endoscopic ones, awarding points for:

  • Age—0 points if less than 60; 1 point if 60 to 79; or 2 points if 80 years or older
  • Shock—1 point if the pulse is more than 100; 2 points if the systolic blood pressure is less than 100 mm Hg
  • Comorbid illness—2 points for ischemic heart disease, congestive heart failure, or other major comorbidity; 3 points for renal failure, hepatic failure, or metastatic disease
  • Endoscopic diagnosis—0 points if no lesion found or a Mallory-Weiss tear; 1 point for peptic ulcer, esophagitis, or erosive disease; 2 points for GI malignancy
  • Endoscopic stigmata or recent hemorrhage—0 points for a clean-based ulcer or flat pigmented spot; 2 points for blood in the upper GI tract, active bleeding, a nonbleeding visible vessel, or adherent clot.

The Rockall score can thus range from 0 to 11 points, with an overall score of 0, 1, or 2 associated with an excellent prognosis.10

The Blatchford scoring system uses only clinical and laboratory factors and has no endoscopic component (Table 1). In contrast to the Rockall score, the main outcome it predicts is the need for clinical intervention (endoscopy, surgery, or blood transfusion). The Blatchford score ranges from 0 to 23; most patients with a score of 6 or higher need intervention.11

Other systems that are used less often include the Baylor severity scale and the Acute Physiology and Chronic Health Evaluation (APACHE) II score.

Does the patient have varices?

All variceal bleeding should be considered severe, since the 1-year death rate is so high (up to 70%). Clues pointing to variceal bleeding include previous variceal bleeding, thrombocytopenia, history of liver disease, and signs of liver disease on clinical examination.

All patients suspected of having bleeding varices should be admitted to the intensive care unit for close monitoring and should be given the highest priority, even if they are hemodynamically stable.

Is the patient hemodynamically stable?

Appropriate hemodynamic assessment includes monitoring of heart rate, blood pressure, and mental status. Tachycardia at rest, hypotension, and orthostatic changes in vital signs indicate a considerable loss of blood volume. Low urine output, dry mucous membranes, and sunken neck veins are also useful signs. (Tachycardia may be blunted if the patient is taking a beta-blocker.)

If these signs of hypovolemia are present, the initial management focuses on treating shock and on improving oxygen delivery to the vital organs. This involves repletion of the intravascular volume with intravenous infusions or blood transfusions. Supplemental oxygen also is useful, especially in elderly patients with heart disease.12

Inspection of nasogastric aspirate

In the initial assessment, it is useful to insert a nasogastric tube and inspect the aspirate. If it contains bright red blood, the patient needs an urgent endoscopic evaluation and an intensive level of care13,14; if it contains coffee-grounds material, the patient needs to be admitted to the hospital and to undergo endoscopic evaluation within 24 hours.

However, a normal aspirate does not rule out upper GI bleeding. Aljebreen et al15 found that 15% of patients with upper GI bleeding and normal nasogastric aspirate still had high-risk lesions (ie, visible bleeding or nonbleeding visible vessels) on endoscopy.

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