Management of Acute Upper GI Bleeding - Clinical Guidelines for the

Publication: 07/03/2013  --
Last review: 13/10/2021  
Next review: 01/10/2024  
Clinical Guideline
CURRENT 
ID: 3263 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Clinical Guidelines for the Management of Acute Upper GI Bleeding

Background

Mortality associated with upper GI bleeding is approximately 10% and is higher in patients with advancing age and comorbidity (e.g. liver, renal, cardiac) and in those on anticoagulants and antiplatelets. Appropriate management of these patients is crucial to reduce morbidity and mortality.

Patients present with haematemesis and/or melaena. Haematochezia can occur in severe cases and is usually associated with haemodynamic instability.
Coffee ground vomiting on its own is an unreliable sign, but can represent an upper GI bleed in the presence of other supporting clinical signs and/or laboratory blood tests.

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Pre-Endoscopy Care

Assessment at presentation

  • NEWS
  • Calculate and record the Glasgow-Blatchford Score (GBS)
  • Calculate and record the Shock Index (heart rate/ systolic blood pressure).
  • Review of risk factors for variceal haemorrhage

MAJOR GI bleeds are defined as requiring high volume or aggressive resuscitation to maintain BP, and/or shock index >1.

Risk Stratification with GBS

Patients with a GBS score of 0 can usually be discharged from the Emergency Department with an outpatient endoscopy.

Assess the urgency for intervention by calculating the Glasgow Batchford Score.

GLASGOW BLATCHFORD SCORE (GBS)

Urea (mmol/l)

Score

Systolic Blood Pressure (mmHg)

 

<6.5
6.5-7.9
8.0-9.9
10.0-25.0
>25.0

0
2
3
4
6

>100
100-109
90-99
<90

0
1
2
3

Haemoglobin for men (g/dl)

 

Other Risk Markers

 

≥13
12.0-12.9
10.0-11.9
<10.0

0
1
3
6

Pulse <100
Pulse Rate >100 bpm
Presentation with Melaena (on PR)
Presentation with Syncope
Hepatic Disease*
Cardiac Failure**                

0
1
1
2
2
2

Haemoglobin for women (g/l)

 

 

 

≥12
10.0-11.9
<10.0

0
1
6

 

Total

 

____ / 23

* Known history or clinical & lab evidence of acute or chronic liver disease ** Known history or clinical & echocardiographic evidence of cardiac failure
Blatchford et al. (2000). Lancet 356: 1318-21

Triage the urgency of intervention based on GBS and haemodynamic stability

Patient source

GBS = 0 or 1
Stable
Low-risk

GBS ≥ 2
Stable
Intermediate risk

 

GBS ≥ 7
Or Unstable
Or suspected varices
High risk

A&E/SAU

Follow CDU protocol

GBS = 0: discharge and book O/P OGD

GBS = 1: discuss with on-call Gastro SpR

Admit to Gastroenterology Ward 91/92 only

Perform OGD within 24 hours

Urgent review by Gastro SpR
Arrange bed on gastroenterology wards (91/92) only

Consider emergency OGD

Consider Level 2 care bed

Existing Inpatients

Discuss with Gastro SpR and perform routine OGD (next available list)

Discuss with Gastro SpR and perform OGD within 24 hours

  Consider emergency OGD    

Consider level 2 care bed

Resuscitation

  • Insert large bore IV cannulae x 2
  • Supplementary oxygen as required
  • Use crystalloids for initial fluid resuscitation
  • Urgent FBC, coagulation, U&E, LFTs
  • Group & Save
  • Cross-match 4 to 6 units of red cells in high risk cases.
  • Urinary Catheter if unstable
  • ECG
  • Early anaesthetic involvement if there is potential of a compromised airway (large volume haematemesis and/or altered conscious level)
  • Keep NBM

Transfusion of Red Cells

Patients with MAJOR GI bleed- crossmatch 4 to 6 units. Commence the transfusion as soon as possible and contact the gastroenterology SpR on call for further advice

The following blood transfusion guidance is recommended for patients who are haemodynamically stable without evidence of ongoing bleeding:

  • Hb < 80 g/L- transfuse with a target Hb of > 80 g/L
  • Hb 80 g/L to 100 g/L- discuss with the gastroenterology SpR who will advise on management
  • Hb > 100g/L- don’t transfuse unless unstable and visible ongoing melaena or haematemesis
  • In suspected variceal bleeding do not transfuse if Hb > 80 g/L unless there is ongoing visible melaena or haematemesis

Anaesthetic Involvement
           
A decision on involving anaesthetic or ITU outreach support should be based on clinical factors including NEWS score and co-morbidities.

Consideration should be given to anaesthetic involvement and intubation/ventilation of unstable patients prior to OGD especially those with: ongoing large volume haematemesis, suspected variceal haemorrhage, altered conscious level

Escalation of Care

  • Refer all patients with a GI bleed and GBS >2 to the on-call Gastroenterology SpR 
  • Refer MAJOR GI bleeds to the on-call Gastroenterology SpR who will arrange to review the patient in the Emergency Department. The on-call GI consultant should be informed within one hour.

The ongoing management of care for patients with a major bleed should rest with the endoscopist on call, directed and supported by the named on-call GI consultant as necessary to ensure timely investigation and treatment to stop bleeding and reduce unnecessary blood transfusion. All patients being taken for OGD to theatres, or to radiology theatres out of hours, must be notified to the on-call GI consultant.

Medical Therapy

Intravenous PPI is usually not indicated pre-OGD

Intravenous prokinetics should be considered for those patients having an emergency endoscopy and where there is concern that retained blood clots in the stomach may obscure endoscopic views and prevent definitive therapy. A stat dose of erythromycin 250mg IV one hour to 90 minutes prior to the endoscopy is the preferred choice. An alternative is metoclopramide 10mg IV if erythromycin is not available or contraindicated.

When a variceal bleed is suspected

  • Terlipressin 2mg qds IV (dose to be adjusted in those considered high risk of an ischaemic event)
  • Piperacillin/Tazobactam 4.5g tds. (If penicillin allergic or MRSA see LTHT guidelines).  Review need for continued antibiotic use at 48hours.

Management of anticoagulants and antiplatelet agents

Endoscopic intervention may achieve haemostasis with minimal or no cessation of anticoagulant or antiplatelet therapy, and should be the first aim. Being on anticoagulation or antiplatelet drugs, abnormal coagulation indices, or a high INR requiring reversal should not delay OGD.

Antiplatelets and NSAIDs

  • Temporarily withhold aspirin.
  • Stop all other NSAIDs
  • Consider risk-benefit ratio of stopping other antiplatelet drugs such as clopidogrel/ticagrelor/prasugrel

There is a high risk of acute vascular events or death if clopidogrel/ticagrelor/prasugrel is discontinued in patients with coronary, carotid or cerebral stents, particularly early after implantation, but extending up to 1 year after this. An urgent consultation must take place between the patient’s responsible specialists (cardiologist for coronary stents, vascular interventional radiologist (VIR) for carotid/ cerebral stents) and the specialist undertaking OGD with regards to risk and benefits of temporary discontinuation. If therapy needs to be discontinued in this context, then this should be limited to a maximum of 5 days as the risk of stent thrombosis increases after this interval. The immediate impact of discontinuing antiplatelet agents in the control of bleeding is limited as antiplatelet activity continues for up to 10 days.

Warfarin/ Direct Oral Anti Coagulants (DOACs)

Assess on an individual basis and discuss with the GI SpR or consultant on-call if required. It is not possible to give unequivocal guidance to cover all situations. Where there is doubt about the management of anticoagulants consider urgent haematology guidance. Andexanet, for the reversal of apixaban or rivaroxaban, can be considered in patients presenting with severe, life-threatening gastrointestinal bleeding or haemorrhage. Approval for use is via the haematology SpR who will then contact the thrombosis/haemtostasis Consultant for authorisation

Low-risk indications for anticoagulation (i.e. uncomplicated AF, distant VTE)

Discontinue. Correction of any reversible coagulopathy is recommended when presenting with clinically significant acute GI bleeding (haematemesis, melaena, severe haematochezia causing haemodynamic instability)

High-risk conditions

  • Mechanical cardiac valve
  • Other prosthetic valve with AF
  • <3/12 since VTE
  • Thrombophilia

Discontinue with or without substitution of heparin depending on the severity of haemorrhage and risk of discontinuing anti-coagulant therapy in minor haemorrhage. Correction of coagulopathy is recommended when presenting with clinically significant acute GI bleeding (haematemesis, melaena, severe haematochezia with haemodynamic instability). 

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Endoscopy Care

Consent should be obtained in line with BSG guidelines.
If there are specific circumstances that make consent a challenge (consent form IV, the use of an interpreter) consideration should also be given to discussing vascular interventional radiology/surgical procedures with the patient at that time

Are any of the following present?

  • ONGOING BLEEDING
  • NOT NORMALISING AFTER RESUSCITATION
  • UNSTABLE EPISODE IN ED REQUIRING TRANSFUSION
  • LOST ≥30% BLOOD VOLUME
  • COAGULOPATHY
  • OTHER ORGAN FAILURE

 
If YES: Consider urgent OGD (within 6 hours), once adequately resuscitated. In theatre during the day if necessary, and always after 10pm.

If NO: Admit. OGD within 24 hours.

Endoscopic therapy

For bleeding related to Peptic Ulcer Disease

Combinations of endoscopic therapy comprising an injection of 1:10 000 adrenaline coupled with either a thermal or mechanical treatment are recommended in preference to single modalities.

Hemospray if all other modalities fail. 

If unable to control bleeding, or further attempts at endoscopic treatment are not considered feasible/appropriate place at least 3 endoscopic clips as close as possible to the bleeding point to facilitate VIR treatment.

For bleeding related to variceal haemorrhage

Oesophageal varices should have band ligation as first line therapy.

Gastric varices should be treated with histoacryl glue injection.
Where haemostasis cannot be achieved with endoscopic therapy balloon tamponade should be attempted. Passage of the balloon under direct endoscopic visualisation is advised. The DANIS stent is an alternative to balloon tamponade and can be used in exceptional circumstances after discussion with an interventional endoscopist and hepatologist.  Hepatology advice should be sought if TIPSS is thought to be appropriate.

For All Patients

  • A clear rebleeding plan must be documented by the endoscopist at every OGD either diagnostic or therapeutic.
  • Patients with peptic ulcer bleeding should be tested for Helicobacter pylori with rapid urease test or stool antigen test and a one week course of eradication therapy commencing at the reintroduction of oral feeding prescribed for those who test positive. A further three weeks anti-secretory ulcer healing treatment should be given.
  • In non-NSAID users, maintenance antisecretory therapy should not be continued after successful healing of the ulcer and Helicobacter pylori eradication.
  • When the rapid urease test is negative in a patient established on anti-secretory therapy prior to presentation, or in patients with blood in the stomach, this should be interpreted with caution, especially in elderly patients, not on NSAID therapy with duodenal ulcers where empiric therapy may be a reasonable option.

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Post-Endoscopy Care

General Principles

  • Patients unstable prior to, during, or after OGD, and undergoing active treatment, should be admitted to a monitored bed.
  • In bleeding occurring in patients already admitted, the GI SpR or consultant on-call can decide whether or not the patient needs to be transferred to the gastroenterology bed base.
  • Patients admitted to the surgical assessment unit (SAU), who are transferred to the endoscopy unit for their acute endoscopy, can usually be returned to SAU as long as they are haemodynamically stable. Unstable patients should be transferred to the gastroenterology ward or level 2/3 bed as appropriate.
  • Patient should be kept NBM until reviewed by Gastroenterologist/SpR on call.
  • Re-bleeding should be assessed by monitoring end organ output (HR, lying and standing BP, Urine Output) half hourly for 4 hours then hourly for the next four hours.
  • The patient should have a repeat FBC within 12 hours.
  • OGD and endo-therapy should be repeated within 24 hours when initial endoscopic treatment was considered sub-optimal (because of difficult access, poor visualisation, technical difficulties) or in patients in whom re-bleeding is likely to be life threatening.
  • Where this is not appropriate (i.e. the initial endotherapy was technically challenging and in the view of the endoscopist, likely to fail again, or if the patient cannot be stabilised) consider selective arterial embolisation or surgery. The GI consultant on-call must be aware of such patients.
  • When interventional radiology procedures are required these must be requested on ordercomms by the GI team.
  • Review indication and restart low dose aspirin for secondary prevention of vascular events in patients with upper gastrointestinal bleeding once haemostasis has been achieved and usually within 72 hours.
  • Discuss the risks and benefits of restarting clopidogrel or warfarin with the appropriate specialist (for example cardiologist or stroke physician) and with the patient.
  • Perform CHADS2VASC2 scoring to risk stratify ongoing requirement for anticoagulation. While this must be individualised, there is now a body of evidence suggesting greater all-cause mortality as a result of thrombotic events from inappropriate discontinuation of anti-coagulation than GI bleeding.

Bleeding from Variceal Haemorrhage

  • Patients with acute variceal haemorrhage treated at OGD, should remain on terlipressin 72 hours and antibiotics for 48 hours after cessation of bleeding.
  • A follow-up procedure should be carried out within 2 weeks and every 2-4 weeks thereafter until eradication of varices achieved.

Bleeding from Peptic Ulcers

  • Patients with bleeding peptic ulcers should have an IV PPI infusion (80mg bolus of omeprazole, followed by 8mg/hr thereafter for 72 hours).
  • Change to oral PPI after IV PPI infusion finishes or stopped
  • Where gastric ulcers have not been biopsied at index OGD

patients should have early repeat OGD to take biopsies either as an in-patient (no sooner than 48 hours) or early outpatient OGD planned with date set prior to discharge and repeated again at 6-8 weeks to ensure ulcer healing.

Radiology

Both CT and VIR (catheter angiography) require active bleeding to identify the site of haemorrhage. DO NOT DEFER CT or IR due to active resuscitation. Imaging and resuscitation should occur simultaneously.  This may require urgent anaesthetic support.  Imaging when the patient is not clinically actively bleeding has a low positive yield and may cause harm.

CT

CT scanning is indicated when:

  • Blood obscures the site of bleeding at OGD and there is clinical evidence of active bleeding
  • The OGD is normal but there is clinical evidence of active bleeding (i.e. a lower GI bleed is likely - see the trust lower GI bleed guideline)
  • Transpapillary (bile duct or pancreatic duct  bleeding is suspected
  • Other indications identified by IR

A triple phase CT (non-contrast, arterial phase and late portal venous phase)
of the abdomen and pelvis scan must be performed in all patients.
The risks of active bleeding outweigh the risks of contrast nephrotoxicity. Minor prior contrast reactions are not a contra-indication to a triple phase CT scan.

There is no place for a non-contrast study in GI bleeding.

If the CT does not show active bleeding a re-bleed plan must be agreed and documented.

Vascular Interventional Radiology (VIR)

Indications for referral:

  • Failed endoscopic control of bleeding
  • Recurrent bleeding despite maximal endoscopic therapy (documented in the OGD re-bleed plan)
  • Cause of transpapillary bleeding on CT
  • Active bleeding or likely culprit lesion on CT and normal OGD

Anticipate that:

  • Haemodynamically unstable patients will require anaesthetic support
  • Agitated or those unable to breath-hold for 10 seconds will require anaesthetic support

A re-bleed plan must be documented at the time of every IR diagnostic or therapeutic study

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Continued bleeding and re-bleeding algorithm for variceal haemorrhage

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Continued bleeding and re-bleeding algorithm for non-variceal haemorrhage

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Provenance

Record: 3263
Objective:

Aim

To provide guidance for clinicians involved in the care of patients who present with an acute upper GI bleed.

Clinical condition:

Upper gastro-intestinal bleeding.

Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

Not supplied

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