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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