Acute upper gastrointestinal haemorrhage is common. Patients require simultaneous resuscitation and clinical assessment followed by referral for endoscopy. There have been significant developments in terms of the acute endoscopic and medical treatment of upper gastrointestinal haemorrhage, as well as the development of prognostic tools to help guide management. Preventing recurrent
haemorrhage is also important. This requires an understanding of both the aetiology and risk factors for recurrence, as well as the medical and endoscopic treatments available to reduce these risks. Acute upper gastrointestinal haemorrhage (bleeding proximal to the duodenojejunal flexure) is a common medical emergency (170 per 100 000 adults
annually). Although its incidence may be declining, the mortality rate of upper gastrointestinal haemorrhage remains high, approximately 6-8%.1Depending on the site and
rate of bleeding, a patient may present with melaena (black, tarry stool), haematemesis (vomiting 'coffee-grounds' or fresh blood), haematochezia (red blood per rectum) or syncope. Melaena may also result from bleeding into the more distal small intestine or proximal colon. The majority of patients with upper gastrointestinal haemorrhage require hospital management. General practitioners have an important role in assessing and resuscitating patients and then managing them following
discharge to reduce the risk of recurrent bleeding. Initial clinical assessment is directed towards the haemodynamic stability of the patient and the requirement for immediate resuscitation. The presenting symptom, past medical history and current medications are important for establishing the
aetiology (see Box and Table 1) and severity of haemorrhage. A history of recent dyspepsia, or use of aspirin or another non-steroidal anti-inflammatory drug (NSAID) may suggest a bleeding ulcer.
The presence of chronic liver disease raises the possibility of variceal haemorrhage. Haematemesis that follows prolonged vomiting or retching may be the result of a Mallory-Weiss tear. A history of syncope may reflect haemodynamically significant bleeding. Vomiting frank blood suggests severe haemorrhage from an arterial or variceal source. In contrast, 'coffee-grounds' emesis is unlikely to reflect active bleeding. Approximately 50-100 mL of
blood is needed to produce melaena. Haematochezia may occur with brisk upper gastrointestinal haemorrhage and is usually accompanied by haemodynamic compromise. ExaminationIt is critical to assess the patient's haemodynamic status by measuring heart rate, blood pressure and postural changes. In haemodynamically compromised patients a fall in blood pressure may follow only a minor change in posture, for example from lying flat to sitting at a 450 incline. Variceal haemorrhage is more likely if stigmata of chronic liver disease are present, particularly if there is evidence of portal hypertension, for example ascites and splenomegaly. An ulcer may cause epigastric tenderness. Digital rectal examination is important to confirm the presence of true melaena. InvestigationsHaemoglobin needs to be measured in all patients but may initially underestimate true blood loss, due to delayed haemodilution of the vascular space. Blood should be sent urgently to transfusion services for cross-matching. Other important tests include platelet count, urea:creatinine ratio, coagulation indices and liver function tests including albumin. Patients with end stage liver disease may have normal liver enzymes, yet have impaired synthetic liver function as evidenced by low albumin, or reduced clotting factors. Risk assessment scoresThe Blatchford score predicts the need for therapy and thus admission. Patients are unlikely to need treatment and therefore may not require admission if they satisfy the following criteria:
This 'fast-track' triage could be used in an emergency department to avoid unnecessary admissions.2 Likewise in regional areas, such a scoring system could help the general practitioner decide if a patient requires immediate transfer to a tertiary referral centre, or whether it is reasonable to discharge the patient with a view to arranging an early outpatient endoscopy at the closest facility. The safety of using the management algorithm in this way is yet to be formally evaluated, and thus patients should continue to be managed on a case by case basis. The Rockall score is frequently used for risk categorisation (Table 2). The score is the sum of each component, calculated before and after endoscopy. This predicts rates of re-bleeding and mortality and can be used in management algorithms, for example whether to admit a patient to an intensive care unit. Post-endoscopy risk scores of 2 or less are associated with a 4% risk of re-bleed and 0.1% mortality. In one study about 30% of patients had post-endoscopy risk scores of 2 or less and thus significant health savings could be achieved by early endoscopy and discharge.3 ResuscitationUntil cross-matched blood is available, resuscitation proceeds with crystalloid or colloid solutions aiming for a systolic blood pressure of greater than 100 mmHg. Thiamine replacement should be considered when there is a history of alcohol abuse. The target haemoglobin concentration is contentious. Some advocate 70-80 g/L for otherwise healthy individuals, without active bleeding, who are haemodynamically stable.4In patients older than 65 or those with cardiovascular disease a target concentration of 90-100 g/L may be more appropriate. Endoscopy - diagnosis and managementAfter resuscitation an endoscopy is arranged. Some patients with profuse haemorrhage require emergency endoscopy, however the majority can be scheduled on the next routine list. The endoscopy should, however, take place within 24 hours of presentation, both to guide management and to facilitate the early discharge of patients with a low risk of recurrent bleeding. When high-risk lesions are seen (ulcers with active spurting vessel or non-bleeding visible vessel) endoscopic therapy significantly reduces re-bleeding rates and mortality.1 A dual-modality endoscopic approach is currently recommended, with a combination of (1:10 000) adrenaline injection and thermal coagulation. Band ligation and sclerotherapy are the two main endoscopic techniques for treating acute oesophageal varices.5 These procedures are less successful in gastric varices, although injection with tissue adhesive may be effective. Medical management of upper gastrointestinal bleedingNon-varicealIn gastrointestinal haemorrhage there is enhanced mucosal fibrinolytic activity, impairing haemostasis.6 Suppressing acid secretion blunts this escalation in fibrinolysis. In this setting high-dose proton pump inhibitor therapy reduces the risk of recurrent bleeding.7 Proton pump inhibitor therapy can be administered parenterally (either intermittently or by infusion) or orally. When high-risk features are present at endoscopy it may be advisable to administer high dose intravenous proton pump inhibitor therapy, that is omeprazole 80 mg (or equivalent) bolus followed by an infusion rate of 8 mg/hour for 72 hours. Where the cost of intravenous proton pump therapy is prohibitive and especially when there are no high-risk ulcer features, an oral proton pump inhibitor may be satisfactory.7 Variceal |