A guide to the estimated blood loss and fluid replacement is given in Table 12.5.
Acute upper gastrointestinal bleeding
Resuscitation and risk assessment
Appropriate management Varices
Peptic ulcer
Major SRH Forrest 1a, 1b, 2a, 2b
Minor SRH Forrest 2c, 3
No obvious cause
Minor bleed Major bleed
Consider angiography, colonoscopy, operative enteroscopy Early discharge Eradicate H. pylori Risk reduction – NSAIDs Endoscopic haemostasis +IV PPI 72 h Rebleeding Success Failure No rebleeding Discharge Eradicate H. pylori Risk reduction – NSAIDs Repeat endoscopic haemostasis Surgery
Good surgical candidate Poor surgical candidate
Interventional radiology Endoscopy (within 24 h)
Figure 12.1 ● Algorithm for management of non-variceal upper gastrointestinal bleeding.
NSAID, non-steroidal anti-inflammatory drug; IV, intravenous; PPI, proton-pump inhibitor; SRH, stigmata of recent haemorrhage.
UPPER GASTROINTESTINAL BLEEDING 154
Endoscopy
Endoscopy should be performed within 24 h. The risk of rebleeding and mortality based on endoscopic findings should be assessed, as shown in Table 12.6 (Forrest et al., 1974; Laine and Peterson, 1994).
■ KEY POINT
Endoscopy should be performed within 24 h and used to assess the risk of rebleeding and mortality.
Table 12.5 Estimated fluid and blood losses in shock
Class 1 Class 2 Class 3 Class 4
Blood loss (mL) ≤ 750 750–1500 1500–2000 > 2000
Blood loss (% blood ≤ 15 15–30 30–40 > 40
volume)
Pulse rate (beats/min) < 100 > 100 > 120 > 140
Blood pressure Normal Normal Decreased Decreased
Pulse pressure Normal or increased Decreased Decreased Decreased
Respiratory rate 14–20 20–30 30–40 > 35
Urine output (mL/h) > 30 20–30 10–20 < 10
Mental status Slightly anxious Mildly anxious Anxious and Confused and confused lethargic Fluid replacement Crystalloid Crystalloid Crystalloid and Crystalloid and
blood blood
Based on American College of Surgeons Committee on Trauma (1997).
Table 12.6 Forrest classification of stigmata of recent haemorrhage (SRH) from peptic ulcer and risk of rebleeding and mortality
Forrest classification of SRH Risk of rebleeding (%) Risk of mortality (%)
Ia Spurting bleeding 55 11
Ib Non-spurting active bleeding
IIa Visible vessel (no active bleeding) 43 11
IIb Non-bleeding ulcer with overlying clot 22 7 (no visible vessel)
IIc Ulcer with haematin-covered base 10 3
III Clean ulcer ground (no clot, no vessel) 5 2
Major SRH, Forrest Ia, Ib, IIa and IIb; minor SRH, Forrest IIc and III. Based on Forrest et al. (1974) and Laine and Peterson (1994).
Management of patients with non-variceal upper gastrointestinal bleeding Endoscopic haemostasis
Endoscopic haemostasis has been shown to significantly reduce rebleeding rates, the need for surgery, and mortality when compared with drug or placebo treatment.
■ KEY POINT
Endoscopic haemostasis has been shown to significantly reduce rebleeding rates, the need for surgery, and mortality when compared with drug or placebo treatment.
The finding of a clot in an ulcer bed warrants targeted irrigation in an attempt to dislodge and treat the underlying lesion. The finding of high-risk endoscopic stigmata (active bleeding or visible vessel in an ulcer bed) is an indication of immediate endoscopic haemostatic therapy (Barkun et al., 2003). Endoscopic therapies may include the following:
● Injection of 1 : 10 000 adrenaline solution in normal saline in quadrants around the bleeding point, and then into the bleeding vessel, using a total of 4–16 mL: this approach achieves primary haemostasis in up to 95 per cent of patients, although bleeding will recur in 15–20 per cent of these patients. There is little evidence that addition of other agents such as sclerosants (e.g. sodium tetradecyl sulphate STD, 1% polidocanol, 5% ethanolamine) reduces the rate of rebleeding. However, there is no consensus regarding the recommended dose or frequency of these substances. The injection of agents that directly stimulate clot formation, such as fibrin glue and thrombin, has been shown to be effective, but these agents are not freely available.
● Thermal haemostasis with either heater probe or multipolar coagulation (bipolar current electrocoagula- tion, BICAP): this is as effective as adrenaline injection. The combination of injection and ther- mal coagulation is superior to either treatment alone (Barkun et al., 2003). Laser therapy is no longer used because of its high cost and the poor portability of equipment.
● Mechanical clips (Haemoclips®): these can be applied to bleeding points and are particularly useful for actively bleeding large vessels. They may be difficult to apply to awkwardly placed ulcers. Endoscopic clips are usually placed over a bleeding site (e.g. visible vessel) and left in place. Clips are currently available in two- and three-pronged configurations. They can be affixed to bleeding sites and typically slough off days to weeks after placement.
Management following endoscopy
Although routine second-look endoscopy is not recommended (Barkun et al., 2003), repeat endoscopy should be considered if there is clinical evidence of active rebleeding, in order to endoscopically confirm and retreat rebleeding, and if there are concerns regarding optimal ini- tial endoscopic therapy due to technical reasons such as excessive blood (consider re- endoscopy within 12–24 h) (Palmer, 2002).
■ KEY POINT
Although routine second-look endoscopy is not recommended, repeat endoscopy (within 12–24 h) should be considered if there is clinical evidence of active
rebleeding and if there are technical concerns with regard to the initial endoscopic therapy.
Pharmacotherapy
An intravenous bolus followed by continuous infusion proton-pump inhibitor (PPI) is effec- tive in decreasing rebleeding and mortality in patients who have undergone successful endo- scopic therapy (Barkun et al., 2003).
UPPER GASTROINTESTINAL BLEEDING 156
■ KEY POINT
Intravenous bolus followed by continuous infusion PPI is effective in decreasing rebleeding and mortality in patients following successful endoscopic therapy.
There are no convincing data to support the use of H2receptor antagonists (Palmer, 2002). In patients awaiting endoscopy, empirical therapy with a high-dose PPI should be considered (Barkun et al., 2003).
Somatostatin, octreotide and interleukin 2 receptor antagonists are not recommended in the routine management of patients with acute UGIB (Barkun et al., 2003).
Surgery
Patients who continue to actively bleed after endoscopy require urgent surgery. Early surgical consultation in patients at high risk of rebleeding and for those who rebleed after endoscopic therapy is indicated. Timing of an operation should, if possible, avoid the hours between mid- night and 7 a.m., as supportive medical services tend to have minimal staffing during this period.
■ KEY POINT
Patients who continue to actively bleed after endoscopy require urgent surgery. The indications for surgery in patients with bleeding peptic ulcers are:
● severe life-threatening haemorrhage not responsive to resuscitation;
● failure of medical therapy and endoscopic haemostasis with persistent recurrent bleeding;
● coexisting indication for surgery, such as perforation, obstruction or malignancy;
● prolonged bleeding with loss of 50 per cent of blood volume;
● second hospitalisation for peptic ulcer bleeding.
A bleeding duodenal ulcer should be under-run with specific ligation of the gastroduodenal and right gastroepiloic arteries. In the present era of PPI therapy, the addition of a vagotomy is unnecessary. Vagotomy with antrectomy is reserved for patients who rebleed after simple under-running of the duodenal ulcer and for those with other ulcer complications such as gas- tric outlet obstruction. Highly selective vagotomy with anatomical closure of the duodeno - stomy or the pyloroduodenostomy in order to preserve the normal pyloric sphincter muscle is an operation reserved for young, stable, low-risk patients with a low risk of recurrent ulcer rate (< 10% at a mean follow-up of 3.5 years), although this procedure is now uncommon.
The surgical management of bleeding gastric ulcer is slightly different and should exclude malignancy as well as control and prevent recurrent bleeding or ulceration. A bleeding gastric ulcer is most commonly managed by a distal gastrectomy that incorporates the ulcer with a gas- troduodenostomy (Billroth I) or a gastrojejunostomy (Billroth II) reconstruction. Alternative options include wedge resection of the ulcer with or without truncal vagotomy and drainage procedure. The type of operative approach relies on the location of the ulcer and the patient’s fitness and haemodynamic stability. Ulcer biopsy and oversewing, thus leaving the ulcer in situ, carries a high risk of rebleeding (20–40%) (Corson and Williamson, 2001) but may be jus- tified in high-risk patients who cannot withstand resection.