UPPER GASTROINTESTINAL

BLEEDING

G.C. SturnioloNicoletta Merlini

Dipartimento di Scienze Chirurgiche e Gastroenterologiche

Sezione di Gastroenterologia

ACUTE UPPER GI BLEEDING

In UK

25.000 hospital admission each year

INCIDENCE:

50 to 150 cases per 105 per year

Palmer, PMJ 2004

AUGIBETIOLOGY

Peptic ulcer disease

Oesophageal/gastric varices

Mallory-Weiss tear

Oesophagitis

Duodenitis/gastritis/erosions

Vascular (Angiodysplasia, Dieulafoy)

Tumours

Aortoenteric fistula

ACUTE UPPER GI BLEEDING

Peptic ulcers

42,5%

Tumours

2,5%

Aortoduodenal

fistula <1%Varices

8,5%

Mallory Weiss

3,5%

Vascular

2,5%

Erosions

15%

Oesophagitis 25%Adapted from

Palmer, PMJ 2004

MORTALITY

Rockall, BMJ 1995

4153 upper GI bleeding

0%

10%

20%

30%

40%

Mort

al it

y %

> 9051-60

31-40

41-50

61-70

21-30

71-80

81-90

MORTALITY in UGIB

0%

10%

20%

30%

40%

50%

Hospital Mortality Bleeding Mortality

Varices

Peptic Ulcer

Erosion

Mallory Weiss Tear

Klebl, Int J Colorectal Dis 2005

Hospital mortality and mortality related to the source of bleeding

in 362 UGIB45,5%

22,7%

29,4%

9,1%

20%

3,8%5,9%

0%

MORTALITY in UGIB

0%

10%

20%

30%

40%

50%

60%

11%

40%

p < 0,05

Mortality of patients during hospitalization

Bleeding only before

admission

Bleeding before + after

admissionAdapted from

Palmer, PMJ 2004

MORTALITY FOR UGIB: Time Trend

0%

5%

10%

15%

20%

Cirrhosis+Non cirrhosis Cirrhosis

1996

2000

1996

2000

11,7%

7,2%

19,5%

11,1%

p=0,03

p=0,05

Fiore, Eur J Gastr Hep 2005

UGIB:Diagnostic Endoscopy

• Identifies the bleeding lesions >95% of sensitivity and specificity

• Morbidity• Mortality• Transfusions• Length of stay• Surgery

• Doesn’t alter patient outcome:

Peterson, NEJM 1981Cappell, Med Clin N Am 2002

UGIB:Therapeutic Endoscopy

• Only patients with persisten or recurrent bleeding

• 80% patients don’t have further

bleeding

• Optimal utilization

IDENTIFY HIGH RISK PATIENTS

UGIB: ROCKALL SCORE

Developed in 1996 to assess risk of mortality and rebleeding

in UGIB patients Rockall, BMJ 1996

Rockall risk score

Variable Score 0 Score 1 Score 2 Score 3

AGE

SHOCK

CO-MORBID

DIAGNOS

MAJOR SRH

< 60

None

NoneMallory-Weiss

No lesions

None or dark spots

60-79

Pulse > 100 bpm

-All other diagnoses

> 80

Fc>100,PAOs <100

Cardiac failure

Malignancy upper GI

Blood in upperGI tract, blood clot

Renal,liver failure

UGIB:ROCKALL SCORE

Retrospective study, 222 patients

0%

10%

20%

30%

40%

50%

Distribution of Rockall Score

% o

f p

ati

en

ts

2

7

654

3 109

8

Bessa, DLD 2006

UGIB:ROCKALL SCORE

Retrospective study, 222 patients

Rebleeding Risk Mortality Risk

0%

5%

10%

15%

20%

25%

30%

Rockall < 5 Rockall > 6

p = ns

0%

5%

10%

15%

20%

25%

30%

Rockall < 5 Rockall > 6

p < 0,001

Bessa, DLD 2006

UGIBWHICH PATIENTS ARE MORE LIKELY

TO REBLEED?

UGIB:Clinical Risk

• Large volume bleeding• Shock• Age > 60 years• Bleeding onset after admission• Comorbidity• Variceal Bleeding

Scoring Systems for UGIB

• Baylor bleeding score (1993)

• Cedars-Sinai predictive index (1996)

• Rockall Score (1996)

• Blatchford Score (2000)

Das, Gastrointest Endosc 2004

UGIB: Blatchford Score• Derived from clinical information at presentation such as:

• Urea• Hb• Blood pressure• Comorbidity (syncope, melena, heart and/or liver disease)

Blatchford, Lancet 2000

BLATCHFORD vs ROCKALL

Blatchford, Lancet 2000

BETTER ROC FOR “CLINICAL INTERVENTION”

PEPTIC ULCERSCLASSIFICATION

FORREST CLASSIFICATION

ACUTE HEMORRHAGE

Forrest I a Arterial, spurting hemorrhageForrest I b Oozing hemorrhage

SIGNS OF RECENT HEMORRHAGEForrest II a Visible vesselForrest II b Adherent clotForrest II c Hematin covered lesion

LESIONS WITHOUT RECENT BLEEDING

Forrest III No signs of recent hemorrhage

Forrest IIb

Forrest IIa

FORREST CLASSIFICATION

Forrest 2c Forrest 3Ulcer with haematin-covered base Ulcer with clean base

Forrest 1bNon-spurting active bleeding

Forrest 1a Spurting bleeding

Forrest 2aNon-bleeding visible vessel

Forrest 2b Non-bleeding with adherent clot

PEPTIC ULCERS:RISK FACTORS?

• Male, Advanced age• History of ulcer disease• Helicobacter Pylori• Corticosteroids• NSAIDs• Blood-thinning drugs

MANAGEMENT OF UGIB

• Resuscitation

• Endoscopy and endoscopic therapy

• Drug Therapy

MANAGEMENT OF UGIB

• Resuscitation

• Endoscopy and endoscopic therapy

• Drug Therapy

RESUSCITATION• Airway, Breathing, Circulation

• Central Venous Pressure (elderly and cardiopathic)

• Crystalloids (carefully in liver disease!)

• Colloids in major hypotension

ShockedShocked Actively bleeding

Hb < 10 g/dL

• Blood transfusion

Palmer, PMJ 2004

Blood Transfusion

Age > 60 yearsHb < 8.2 g/dL

WHEN SHOULD WE TRANSFUSE PATIENTS?

Cardiologic Evaluation

cTropI Curve Gastro PD, BLISC

MANAGEMENT OF UGIB

• Resuscitation

• Endoscopy and endoscopic therapy

• Drug Therapy

UGIB: TO SCOPE • Early endoscopy identifies and treats patients with high risk of rebleed improving patient outcomes

• PPI therapy alone is not as effective as endoscopic therapy for high risk lesions

UGIB: NOT TO SCOPE

• No benefit from early

endoscopy if the findings do

not change patient care

DRUG THERAPY

Merki, Gastroenterology 1996

Time with intragastric pH>4 / 24h

0%

20%

40%

60%

80%

100%

IV PPI IV H2RA

Day 1

Day 3

p<0,001

93%96%

67%

43%

IV PPI vs IV RANITIDINE

MANAGEMENT OF NON VARICEAL BLEEDING

Non-variceal, upper GI bleeding

IV PPI bolus + infusion

Upper Endoscopy

Low-risk stigmata

Oral PPI therapy

High-risk stigmata

Endo therapy +IV PPI Triadafilopoulos,

Alim Pharm Ther 2005

OESOPHAGEAL VARICES

• 80-90% CIRRHOSIS• BLEEDING PREVALENCE: 30-40%• MORTALITY I BLEEDING: 20-45%

• PRIMARY PREVENTION

• SECONDARY PREVENTION

• TREATMENT ACUTE BLEEDING

CIRRHOSIS SMALL VARICES LARGE VARICES

INCIDENCE/YEAR 5-10%

INCIDENCE/YEAR

5-30%

ACUTE BLEEDING

INCIDENCE/YEAR

5-50%

MORTALITY 30-50%

PRIMARY PREVENTION

50% BLEEDING 25-45% MORTALITY’

REBLEEDING60% 1 YEAR

RISK FACTORS

• CHILD B-C

• EXTENSION (63% Ls vs 45% Li)

• DIMENSION (F1,15%;F2,32%;F3,68%)

• RED WALL MARK

(red spots e wall marking 76% vs 17% without)

• COLOR (blue 80% vs white 45%)

• PORTAL VEIN PRESSURE (> 12 mmHg)

HIGHER BLEEDING RISK

VARICEAL BLEEDING

RES

USC

ITATI

ON

•UEC

•PLA

SMA E

XPA

NDER

S

EGDS IN 12 HRS

De Franchis, J Hepatol 2000

ANTIBIO

TICVASOACTIVE

DRUGS

MEDICAL TREATMENT ANTIBIOTICS

INFECTIONS

35-66% BLEEDING CIRRHOTICS

• UTI 12-29% E.Coli + Klebsiella

• SBP 7-23% Gram -/+

• PULMONARY INFECTIONS 6-10%

• SEPSI 4-11%

Dell’Era, APT 2004

INFECTIONS

BLEEDING CONTROL FAILURE

MORTALITY RELATED BLEEDING

• PREDICTIVE FACTOR OF REBLEEDING

MEDICAL TERATMENTVASOACTIVE DRUGS

TERLIPRESSIN 2 mg e.v. qd 4-6 hrs per 24 hrs

then

1 mg e.v. qd 6 hrs per 4 days

VASOACTIVE DRUGS, BLOOD TRASFUSION

RESUSCITATION, COLLOIDS, ANTIBIOTICS

EGDS

MEDICAL TREATMENT

Vasoactive drugs (5 days long)

VARICEAL BAND LIGATIONSCLEROTHERAPY

Failure

II EGDS

BLAKEMORE

Surgery (child A) TIPS (child B,C)Lata J et al Dig Dis 2003

Failure

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