Acute upper gastrointestinal bleeding

Assessment and risk stratification

All patients presenting with UGIB require prompt assessment using a validated assessment tool. Early assessment identifies patients at high risk of death, of further bleeding and those requiring intervention, including surgery. Many predictive tools have been described for risk stratification of people with UGIB, but there is substantial variation in the outcomes assessed and in methodological quality.⁴ The National Institute for Health and Care Excellence advocates use of the Glasgow–Blatchford Score (GBS) at initial assessment (Table 1) and the full Rockall score after endoscopy to risk stratify all UGIB patients (Table 2).² Both scores perform similarly in predicting mortality; however GBS predicts an individual's need for intervention and transfusion more accurately, and may therefore be more appropriate as a guide for early clinical decisions.⁵ Low-risk patients with a GBS of zero can be safely managed without admission.⁶

Early pharmacotherapy

Pharmacotherapy prior to endoscopy for UGIB may be influenced by the suspected cause. Where there is a high suspicion of variceal bleeding (those with established cirrhosis, signs of liver disease or previous variceal bleeding), intravenous terlipressin reduces mortality and the requirement for additional procedures, and improves initial haemostasis.² These patients are also at increased risk of bacterial infection, with the risk highest in those with advanced liver disease (Child B and C). All patients with suspected variceal bleeding should therefore be considered for broad-spectrum antibiotics, with the agent used determined by local antibiotic resistance patterns.²

In the overall cohort of those with UGIB, use of PPIs before endoscopy does not reduce mortality, surgery or rebleeding.¹⁰ However, stigmata of recent haemorrhage and the need for intervention at index endoscopy may be reduced, suggesting PPIs might have a role when endoscopy is delayed or cannot be undertaken.¹⁰ Intravenous erythromycin, through its prokinetic action, may optimise mucosal views, reduce the need for a second look endoscopy and reduce blood transfusion requirements; however, it has not been widely recommended.¹¹

Timing of endoscopy

Endoscopy following UGIB is well established in clinical practice, giving a diagnosis, prognostic detail and permitting therapeutic intervention. Urgent endoscopy should be undertaken immediately after stabilisation of initially unstable patients, and within 24 hours of admission for all other UGIB patients.² Evidence to support this is difficult to interpret. Although observational studies suggest a benefit of endoscopy within 24 hours following admission in reducing hospital stay and need for surgical intervention,¹² the inability to demonstrate a clear benefit for early endoscopy may be due to the case mix in randomised controlled trials¹¹ or uncontrolled confounding variables in the UK national audit.^1,2

Endoscopic interventions

For ulcer bleeding, endoscopic therapy is required if active bleeding is identified or if endoscopic features suggest a high risk of rebleeding. High-risk features include ulcers with an active, spurting vessel, non-bleeding visible vessel, active oozing or adherent clot.¹² Therapy comprises a combination of adrenaline injection to the ulcer with another modality: either mechanical (eg endoscopic clips) or thermal (eg bipolar electrocoagulation, heater probe) to achieve haemostasis.^2,12 If haemostasis is not achieved at endoscopy for non-variceal UGIB, there should be early consideration of interventional radiology (angiography ± embolisation) or surgery in unstable patients, depending on local availability and expertise.² If patients rebleed having achieved initial haemostasis at endoscopy, then a further attempt at endoscopic control of bleeding should be made.¹² Both failed primary haemostasis and rebleeding are associated with increased mortality.² Novel endoscopic haemostatic devices or sprays may be useful adjuncts but more trial data are required to establish their position in clinical practice.

The first-line treatment for oesophageal varices is endoscopic band ligation, and for gastric varices is intravariceal injection of cyanoacrylate glue. Continued bleeding or early rebleeding despite initial endoscopic treatment occurs in 10–20% of patients and balloon tamponade, as a temporising measure, or a transjugular intrahepatic portosystemic shunt may be required.¹³

Pharmacotherapy

Following haemostasis, all patients with high-risk ulcers should be commenced on intravenous PPI therapy for 72 hours. Following this, twice daily PPI for a further 11 days may be beneficial.¹⁴ For low-risk ulcers (clean base, flat pigmented spots only), once daily, oral PPI is appropriate. H pylori eradication given alongside acid suppression in those positive for the organism on mucosal biopsy reduces the risk of subsequent rebleeding.¹²

Patients on antiplatelet therapy, anticoagulants and non-steroidal anti-inflammatory drugs (NSAIDs) prior to UGIB require special attention. Currently, international guidance recommends withholding aspirin until haemostasis is achieved and restarting within 7 days (ideally 1–3 days) if it is needed for secondary prevention of vascular events.^2,12 The benefits and risks of continuing clopidogrel in the context of UGIB should be made following consultation with the patient and relevant specialties (cardiology and haematology).

When an NSAID may have caused ulcer bleeding, the NSAID should be withheld during the acute phase and their indication reviewed.² If NSAIDs need to be continued then a cyclooxygenase-2-selective NSAID at the lowest effective dose plus daily PPI is recommended.¹² There is a paucity of data on the management of anticoagulants (warfarin, rivaroxaban and dabigatran) following UGIB. The drug would usually be withheld with reintroduction dependent upon thrombotic risk and influenced by rebleeding risk.¹⁵

Following variceal haemorrhage, terlipressin should be continued for 3–5 days after endoscopic treatment and haemostasis. Patients should then be considered for secondary prophylaxis including non-selective b-blockers and surveillance endoscopy with endoscopic band ligation.