MANAGEMENT OF A PT WITH HEMATEMESIS

Dr. Salem Mohammad BazarahMD, M.Ed, FACP, FRCPC, FRCPC (GI) & PhD

A common medical condition 250,000 – 500,000 admissions/year

US UGI bleeding incidence 100/100,000

adults Incidence increases 20-30 fold from third

to ninth decade of life LGI bleeding incidence 20/100,000

adults Overwhelmingly disease of the elderly

GI bleeding stops spontaneously in 80 %

Morbidity Data

Majority will receive blood transfusions

2 – 10 % require urgent surgery to arrest bleeding

Average LOS 4 – 7 days Mortality rates for UGI bleeding 2 –

15 % Mortality for patients who develop

bleeding after admission to hospital for another reason is 20 – 30 %

Costs

Average hospital costs exceed $ 5,000 per admission

Most of this for hospital bed and ICU stays rather than physician fees, blood products, diagnostic tests, or medications

Reduction of hospital admissions and LOS has greatest potential to reduce costs

UGI bleeding:Nomenclature

Hematemesis 25 % Melena alone 25 %, 50 – 100 cc of

blood will render stool melenic Hematochezia 15 %, seen in massive

UGI hemorrhage “Red blood” hematemesis “Coffee ground” emesis

Indications for Hospitalization and Intensive Care

Traditional: Endoscopy on the day of admission or on the day after

Recent studies: Complete endoscopic risk stratification PRIOR to admission

Between 25- 30 % of patients with UGI bleeding could be discharged from the Emergency Department

Predictors of Outcome in UGI bleeding

Clinical Endoscopic

Age > 60 y Low risk endoscopic findings

Hemodynamic instability High risk endoscopic findings

Comorbidities

Hematemesis (red blood)

Coagulopathy

Ulcer Appearance and Prognosis

Appearance Prevalence % Rebleed % Mortality %

Clean base 42 5 2

Flat spot 20 10 3

Clot 17 22 7

Visible vessel 17 43 11

Active bleeding 18 55 11

History

45 yrs male with 1 day hx of vomiting blood

Approach

Assess the severity Resuscitate Establish the site of bleeding Endoscopic intervention Reassess severity: liase with surgical

team Medical treatment Indications for surgery

Assessing severity: Rockall criteria

Criterion Score Age <60 years 0

60-79 yrs 1>80 years 2

Shock None 0Pulse & sBP >100 1sBP <100 2

Co-morbidity None 0Cardiac/any major

2Renal/liver/malig. 3

Total initial score (max = 7)

Implications of initial scoreInitial risk score (pre-endoscopy)

Score Mortality0 0.2%1 2.4%2 5.6%3 11.0%4 24.6%5 39.6%6 48.9%7 50.0%

Rockall TA et al Gut 1996; 38: 316-21

Resuscitate

Large bore intravenous cannula x 2 X-match 4 units, give colloid & transfuse if

Fresh melaena on PR Postural hypotension >15mm/Hg sBP <100mmHg

Cross match 6 units for Suspected variceal bleeding

Otherwise group and save serum only

Resuscitation Indications for CVP

Rockall score > 3, first rebleed, or inadequate access

Insert urinary catheter if CVP appropriate

Urea/creatinine ratio If >unity (eg 12.4/90), then upper GI bleed

likely

Monitor Pulse & BP ‘?hrly’ Guide of halves: if pulse higher or BP lower

than last recording, then halve the time to the next recording

If pulse trend rises on 3 occasions, call senior cover

Establish site of bleeding Endoscopy on next available list Ideally <24hr

Out of hours endoscopy If a surgical decision depends on the result Therefore consent ‘endoscopy, ?proceed’

Check endoscopy report for stigmata of recent haemorrhage intervention

Stigmata of recent haemorrhage Clean ulcer base (rebleed

<1%)

Black spots ulcer base (rebleed 5%)

Stigmata of recent haemorrhage

Fresh clot (rebleed 30%)

Visible vessel (rebleed 50%)

Stigmata of recent haemorrhage

Bleeding vessel (rebleed 80%)

Upper GI Bleeding

Klaus Gottlieb, MD, FACP, FACG

Source of bleeding

Common

DU (35%) GU (20%) Oesophagitis (6%) Mallory-Weiss (6%) No source found

(20%)

Uncommon/Rare

Varices Tumour Aortoenteric

fistula Dieulafoy Haemobilia Angiodysplasia

Intervention Endoscopic injection with

Adrenaline 1:10 000, thrombin, sclerosant, or saline all halve the risk of rebleeding

As good as heater probe, laser therapy

Tranexamic acid 1g iv three times daily for 72hr reduces mortality

Omeprazole 60mg iv stat and infusion 8mg/hr for 72hr may reduce mortality after endoscopic

intervention Nothing else has been shown to work

Do not prescribe iv ranitidine, or oral PPI until after endoscopy

Reassess severity: update Rockall

Score Endoscopic diagnosis

No lesion, or M-W tear 0 All other diagnoses 1 Malignancy of upper GI tract 2

Stigmata of recent haemorrhage None/haematin 0 Clot, visible vessel,blood in stomach 2

Final score after endoscopy (max 11)

Updated Rockall score

Initial score (pre-endoscopy)Score Mortality0 0.2%1 2.4%2 5.6%3 11.0%4 24.6%5 39.6%6 48.9%7 50.0%

Final score (after endoscopy)Score Mortality0 0%1 0%2 0.2%3 2.9%4 5.3%5 10.8%6 27.0%7 17.38+ 41.1%

Further management

Liase with surgeons if Initial score >3 (ie if CVP necessary) Posterior duodenal ulcer Final Rockall score >4

After endoscopy Eat & drink if no stigmata, or haematin only Clear fluids for 12 hr if endoscopic

intervention NBM only if haemostasis not secure (varices)

Re-examine after 4-8hr for signs rebleeding

Ring blood bank to keep blood available for 24hr after endoscopic intervention

Signs of rebleeding Rise in pulse rate Fall in CVP Decrease in hourly urine output Further haematemesis or fresh melaena

Look at the patient as well as the charts! Act if rebleeding suspected

FBC and transfuse Ensure large bore access, central line and

catheter Call surgical team

Indications for surgery Early surgery (esp. elderly) assoc. with lower

mortality

Age over 60 years Transfusion >4 units in 24hr One rebleed Continued bleeding

Age under 60 years Transfusion >8 units in 24hr Two rebleeds Continued bleeding

Decision not to operate should be taken by consultant

Special notes - Variceal bleeding Suspect variceal bleeding if…..

- Alcohol Hx- Deranged LFT’s- Jaundice*- Hyponatraemia*- Ascites*- Coagulopathy- Low platelets- Previous Hx of varices*

Special notes – Variceal Bleeding Resuscitate Correct coagulopathy (FFP x 4 and vit K IV) Endoscopy and banding/sclerotherapy Glypressin 2mg iv stat and 1-2mg repeated 4hrly Treat other aspects of decompensation

Ascites (spironolactone, no N/saline) Encephalopathy (lactulose, no sedation) Renal impairment (avoid hypovolaemia) Malnutrition (iv vitamins, fine bore feeding) Underlying liver disease (hepatic ‘screen’, aFP etc)

Post-bleed prophylaxis

Summary

Objective assessment (Rockall criteria) Resuscitation before endoscopy Monitor by rule of halves: look for trends No role for empirical acid suppression

Critical appraisal of endoscopy report Liaise with surgeons early Discriminate between high & low risk

patients