Acute upper gastrointestinal bleeding

Matthew Kurien; Alan J Lobo

doi:10.7861/clinmedicine.15-5-481

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Fig 1.
(a) Endoscopic appearance of oesophageal varices. (b) Endoscopic appearance of oesophageal varices after endoscopic band ligation.
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Fig 2.
Gastric ulcer close to the pylorus.

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Table 1.

Risk stratification score: Glasgow–Blatchford Score.²^,⁶

Admission risk factor	Score
Blood urea
6.5–7.9	2
8.0–9.9	3
10.0–25.0	4
>25.0	6
Haemoglobin for men (g/L)
120–129	1
100–119	3
<100	6
Haemoglobin for women (g/L)
100–119	1
<100	6
Systolic blood pressure (mmHg)
100–109	1
90–99	2
<90	3
Other markers
Pulse ³100 bpm	1
Presentation with melaena	1
Presentation with syncope	2
Hepatic disease	2
Cardiac failure	2
Score ³6 associated with >50% likelihood of needing intervention.

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Table 2.

Risk stratification score: full post-endoscopy Rockall score.²

Risk factor	Score
	0	1	2	3
Age, years	<60	60–79	>80
Shock	No shock	Pulse >100 bpm	Systolic blood pressure <100 mmHg
Comorbidity	Nil major		CHF, IHD, major morbidity	Renal failure, liver failure, metastatic cancer
Diagnosis	Mallory–Weiss	All other diagnoses	GI malignancy
Evidence of bleeding	None		Blood, adherent clot, spurting vessel
CHF = chronic heart failure; GI = gastrointestinal; IHD = ischemic heart disease.

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Box 1.

Management of acute UGIB. Key priority recommendations from NICE clinical guidelines (CG141). Reproduced with permission.²

Risk assessment

1. Use the following formal risk assessment scores for all patients with UGIB:

> Blatchford score at first assessment

> full Rockall score after endoscopy.

Timing of endoscopy

1. Offer endoscopy to unstable patients with severe UGIB immediately after resuscitation.

2. Offer endoscopy within 24 hours of admission to all other patients with UGIB.

3. Units seeing >330 cases a year should offer daily endoscopy lists. Units seeing <330 cases a year should arrange their service according to local circumstances.

Management of non-variceal bleeding

1. Do not use adrenaline as monotherapy for the endoscopic treatment of non-variceal UGIB.

2. For the endoscopic treatment of non-variceal UGIB, use one of the following:

> a mechanical method (for example, clips) with or without adrenaline

> thermal coagulation with adrenaline

> fibrin or thrombin with adrenaline.

3. Offer interventional radiology to unstable patients who re-bleed after endoscopic treatment. Refer urgently for surgery if interventional radiology is not promptly available.

Management of variceal bleeding

1. Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.

2. Consider TIPS if bleeding from oesophageal varices is not controlled by band ligation.

Control of bleeding and prevention of re-bleeding in patients on NSAIDs, aspirin or clopidogrel

1. Continue low-dose aspirin for secondary prevention of vascular events in patients with UGIB in whom haemostasis has been achieved.

NICE = National Institute for Health and Care Excellence; NSAIDs = non-steroidal anti-inflammatory drugs; TIPS = transjugular intrahepatic portosystemic shunts; UGIB = upper gastrointestinal bleeding.