Upper GI bleed management

ABCDE Management

• Follow usual ABCDE approach
  • IV fluid resuscitation (aim for systolic blood pressure ~100)
  • In massive blood loss, transfuse blood, FFP and platelets as per local massive haemorrhage protocol 
  • Blood transfusion if Hb <7g/L in variceal bleed, <8g/L in non-variceal bleed, or shock
  • The patient must be haemodynamically stable before endoscopy

Specific treatment

• Acute variceal bleed (suggested by history/signs/results consistent with chronic liver disease or portal hypertension):
  • Terlipressin 
  • Prophylactic IV antibiotics 
  • Endoscopic intervention (variceal band ligation)
• Non-variceal bleed (e.g. peptic ulcer, Mallory-Weiss tear, oesophagitis):
  • IV proton pump inhibitor 
  • Endoscopic intervention (adrenaline injection, clips, or thermocoagulation)
• In all patients:
  • Keep NBM
  • Transfuse as above
  • Correct any clotting abnormalities
    • On warfarin: prothrombin complex concentrate + vitamin K
    • On direct oral anticoagulant: Idarucizumab for dabigatran; Andexanet alfa for apixaban/rivaroxaban; consider prothrombin complex concentrate for others/if not available 
    • ↓Platelets <50×10⁹/L: platelet transfusion
    • ↑INR (not due to warfarin): vitamin K (if INR ≥1.5) ± FFP (if INR ≥2)
    • ↓Fibrinogen <1g/L: cryoprecipitate 
  • Stop any antiplatelets or anticoagulants
  • Treat any concurrent issues, e.g. encephalopathy, alcohol withdrawal
• Other interventions that are less commonly used
  • Interventional radiology (embolisation) 
  • Surgical intervention
  • Transjugular Intrahepatic Portosystemic Shunt (for resistant varices)

Scoring systems

Glasgow-Blatchford score (pre-endoscopy)

• Assesses likelihood patient will need intervention
• Score 0 = can manage as outpatient; score ≥1 = manage as inpatient)
• Takes into account haemoglobin, urea, SBP, sex, HR, presence of melaena, recent syncope, history of liver disease or heart failure (Blatchford et al. 2000)

Rockall score (post-endoscopy)

• Mortality risk assessment
• Score ≤2 = good prognosis; score >8 = high mortality risk
• Takes into account age, shock, comorbidities, diagnosis and evidence of bleeding (Rockall et al. 1996)

Preventing further bleeding

Treat the cause/reduce the risk of re-bleeding:

• Oesophageal varices
  • Carvedilol (β-blocker that reduces portal venous pressure)
  • Variceal banding
  • Transjugular Intrahepatic PortoSystemic Shunt
  • Liver transplant
• Peptic ulcer
  • Proton pump inhibitor 
  • H. pylori eradication if +ve
  • Avoid precipitants, e.g. NSAIDs

Reference: NICE ‘CG141 Acute upper gastrointestinal bleeding in over 16s: management’ 2016

Test your knowledge with some questions

How does terlipressin work in a variceal bleed?

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What is a TIPS? How is it undertaken and how does it work?

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A patient has a TIPS and then becomes confused. What has happened? What is your initial management?

Hepatic encephalopathy is a common complication of a TIPS procedure. Management is supportive with lactulose and rifaximin. Learn more about complications of cirrhosis here.

Try an OSCE stations

1. Upper GI bleed
2. Find more here