Management of Upper Gastrointestinal (GI) Haemorrhage

Introduction

• 80% of upper GI bleeding will stop spontaneously.
• Age, comorbidities and signs of significant blood loss (e.g. shock and melaena) increase risk.
• Liver disease and variceal bleeding have much higher mortality rates (refer to separate guideline on the Management of Suspected Variceal Bleeding).

Assessment

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

• Assess pulse and BP (including postural BP if not hypotensive).
• Check for evidence of significant blood loss, including rectal examination for melaena. If melaena is present it implies that there has been significant blood loss.
• Check FBC, U&Es and LFTs.
• Check coagulation if suspected liver disease or on anticoagulation.
• Check medication – NSAIDs (non-steroidal anti-inflammatory drugs), aspirin and other antiplatelets, anticoagulants.
• If haemodynamically unstable, resuscitate and discuss with on-call endoscopist / surgical team regarding organising urgent endoscopy after resuscitation.
• Calculate Glasgow Blatchford score (GBS). It is the best early (pre-endoscopic) risk score. If GBS score:
  • ≤1 at presentation then patient can be discharged with early outpatient endoscopy arranged, unless admission required for other reasons. 
  • >1 patient should be endoscoped on the next available list within 24 hours.

General management

All patients:

• Group and save or crossmatch as clinically indicated.
• Continue aspirin but stop NSAIDs.
• Suspend clopidogrel, other antiplatelets and anticoagulants.
• Consider reversing anticoagulation (depends on severity of bleeding and indication for anticoagulation). 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.
• Repeat Hb as clinically indicated.

Patients with haemodynamic compromise and/or significant comorbidities have higher mortality, particularly if elderly. In these patients:

• Crossmatch 4 units
• IV access x 2 – use green (18G) needle or larger
• Consider HDU
• Resuscitate aggressively. Use blood volume expanders or sodium chloride 0.9% to keep pulse <100bpm, systolic BP >100mmHg, urine output >30ml/hour. Tranfusion at threshold of 70-80g/L is recommended in most patients but should be considered at higher thresholds if significant ischaemic heart disease or major bleeding.

Contact senior support to decide on timing of urgent endoscopy.

Endoscopy

• Fast for ≥3 hours
• Consent
• Venflon in situ
• Ensure case notes and observation charts go with patient.

Post endoscopy

If no major stigmata of bleeding and no sinister pathology identified, consider patient for early discharge.

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.

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. 

Arrange a Helicobacter stool antigen test for patients with peptic ulcer disease:

• 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.

If varices present, see separate guideline for management. 

On discharge

• Continue PPI for at least 6 weeks.
• Repeat endoscopy in 8 weeks if gastric ulcer found.