Management of Upper Gastrointestinal Bleeding (UGIB)

Introduction

Cardinal features are haematemesis (fresh red, or altered 'coffee ground' blood) and melaena. There may be associated collapse, haemodynamic instability, anaemia and an isolated rise in urea.

Liver disease and variceal bleeding have much higher mortality rates (refer to separate guidelines for the management of Acute Liver Failure or Suspected Variceal Bleeding).

UGIB (haematemesis and/or melaena) originates from the oesophagus, stomach, and/or duodenum; it is investigated with gastroscopy. It is to be distinguished from lower gastrointestinal bleeding, which originates from the colon, and manifests as fresh rectal bleeding or with blood that is mixed with the stools; this is investigated by flexible sigmoidoscopy or colonoscopy.

Assessment

See the British Society of Gastroenterology website for the Upper GI bleed care bundle.

• ABCDE structured assessment with a focus on haemodynamic status (pulse and blood pressure), PR exam for melaena* and presence of signs suggestive of chronic liver disease (jaundice, ascites and encephalopathy).
• Insert one or more intravenous cannulae as soon as possible after presentation with UGIB, and before patients suffer from haemodynamic collapse. The patient may become unstable unexpectedly.
• Check FBC, U&Es, LFTs, coagulation screen / INR, and Group and Save or Crossmatch, as appropriate.
• Calculate Glasgow Blatchford score and stratify risk (≤1 = low risk and ≥2 = high risk).
• Stratify UGIB by haemodynamic stability (stable vs unstable) and likely underlying aetiology (non-variceal vs variceal). If there is concern about variceal bleeding then refer to Suspected Variceal Bleeding.

*Presence of melaena implies that there has been significant blood loss.

General management

There are 3 stages for the management of UGIB:

• Pre-Endoscopy Assessment and Stabilisation;
• Endoscopy +/- Endoscopic Intervention (this will not be covered in this guideline);
• Post-Endoscopy Care.

Pre-Endoscopy

All patients:

• Suspend clopidogrel, other antiplatelets and anticoagulants
• Continue aspirin but stop NSAIDs.
• Consider reversing anticoagulation (depends on severity of bleeding and indication for anticoagulation). Aim for an INR of less than 2.5. For further information, refer to the Management of Over-Anticoagulation for Patients on Warfarin or Phenindione guideline and Reversal of Apixaban, Edoxaban and Rivaroxaban in Major Haemorrhage or Prior to Emergency Procedures guideline (links only active if accessing via NHS network).
• For patients who need to be admitted, senior input is required to decide place of care (e.g. general ward, HDU, or ICU). This decision needs to be taken before referring patients for endoscopy in order to ensure their safe patient transfer.
• Comorbid conditions (e.g. hypoxia, glycaemic state, arrhythmias, heart failure): All possible efforts should be made to stabilise these even if this results in some delay to performing the endoscopy to ensure patients tolerate the procedure safely.

N.B. Do not use tranexamic acid unless specifically advised by Gastroenterology (randomised trials have not shown efficacy in UGIB).

Haemodynamically unstable patients:

• Nil by mouth
• Crossmatch 4 units
• IV access x 2 – use green (18G) needle or larger
• Consider HDU or ICU as appropriate
• Resuscitate: Use sodium chloride 0.9% to keep pulse <100bpm, systolic BP >100mmHg, urine output >30ml/hour. Transfusion at threshold of 70-80g/L haemoglobin is recommended in most patients but should be considered at higher thresholds if significant ischaemic heart disease or major bleeding.
• Discuss with on call Gastroenterologist / Surgeon regarding urgent endoscopy after resuscitation (should be done within 24 hours).
• In patients not suspected to have a variceal UGIB and who are successfully resuscitated, endoscopy may often be deferred to the next bleeding list in hospitals with daily bleeding lists (if any doubt over need for out of hours endoscopy then discuss with on call Surgeon).

Haemodynamically stable patients:

• Calculate Glasgow Blatchford score to determine need for inpatient endoscopy.
• If score:
  • ≤1 (low risk) at presentation then patient can be discharged with early outpatient endoscopy arranged, unless admission required for other reasons.
  • ≥2 (high risk) at presentation then patient should have an endoscopy on the next available list, ideally within 24 hours.

Endoscopy

Methods for referring for endoscopy will vary according to hospital. If uncertain, ask for advice from a senior.

Before sending patient for inpatient endoscopy, ensure the following is arranged (also see notes above under pre-endoscopy):

• Fasted (minimum 3 hours)
• Appropriate IV access in place
• Group and Save or Crossmatch as appropriate
• Ensure case notes and observation charts go with patient
• The UGIB Bundle attached to the referral form for endoscopy.

Post-endoscopy

• Ensure endoscopy report is reviewed on return to ward in case action is required.
• Assuming successful haemostasis, aspirin should be continued for secondary prevention of cardiovascular disease, with other antiplatelets and anticoagulation reintroduced on a case-by-case basis.
• If no major stigmata of bleeding and no sinister pathology identified, consider patient for early discharge, unless advised otherwise in the report.

Peptic ulcer disease

If high risk stigmata requiring endoscopic therapy, treat with IV esomeprazole.

If no endoscopic therapy, prescribe either lansoprazole oral 30mg or omeprazole oral 20mg once daily. N.B. Follow the advice given on the endoscopy report.

Continue aspirin in patients with peptic ulcer disease (providing indication is still valid) but permanently stop NSAIDs. Suspend clopidogrel, other antiplatelets and anticoagulants in the acute bleeding situation but aim to restart once haemostasis is achieved. If patient is on dual antiplatelet therapy for coronary stents, discuss the risks versus benefits with the interventional cardiologist but clopidogrel should be withheld for a maximum of 5 days. 

Where possible, H pylori urease test (CLO or equivalent) is performed for patients with peptic ulcer disease during endoscopy and the result is phoned to the ward or call endoscopy reception at ext 27713 (University Hospital Crosshouse) or 14240 (University Hospital Ayr).

• If positive for H. pylori – see eradication regimen.
• If negative for H. pylori and not on NSAIDs – maintain on lifelong PPI (see above for choice and dose).
• If re-bleeding occurs (fresh melaena or haematemesis associated with a drop in Hb of 20g/L) – seek senior help, including surgical review or referral for repeat endoscopy.

If varices present, see separate guideline for management. 

Resuming oral intake post-endoscopy:

• Stable patients with low risk of bleeding (no stigmata of recent bleeding or no requirement for endoscopic intervention) may resume oral intake 2 hours post-endoscopy. N.B. This may facilitate early discharge.
• If high risk stigmata requiring endoscopic therapy, patients are kept nil by mouth with IV fluids and IV esomeprazole infusion for 72 hours. 

On discharge

• Continue PPI for at least 6 weeks.
• Repeat endoscopy in 8 weeks if gastric ulcer found.
• Ensure successful eradication of H.pylori (see Management of Helicobacter Pylori guideline).