GI Bleeding Emergencies

DR. YONG SHIH MUN

DEPARTMENT OF GASTROENTEROLOGY & HEPATOLOGY
HOSPITAL QUEEN ELIZABETH, KOTA KINABALU, SABAH
What is the difference between Upper and
Lower GI Bleed ?

The ligament of Treitz (4th portion of duodenum) is the cut-

off between an upper and lower GI bleed.
Anatomy of GI tract

Upper GI tract : Upper endoscopy

(OGDS)

Mid GI tract : Enteroscopy, Video

capsule enteroscopy

Lower GI tract : Colonoscopy

Aetiology of Upper GI Bleeding

Elsevier Kumar & Clarke : Clinical Medicine 6e-

www.studentconsult.com
Peptic ulcer bleeding
Forrest Classification
Prevalence of Forrest Grades among patients
with PUB
Risk of rebleeding correlates with endoscopic
bleeding stigmata
Prevention is the key

 Acid suppression is important

 What is the appropriate pH ?

Answer : pH > 4
An intragastric pH >/= 4 is considered appropriate to prevent mucosal
injury
pH 4 is a critical threshold for maximum
pepsin activity
Acid suppression is important as pH>6 is
required to maintain platelet aggregation
Initial management of acute upper GI
Bleeding

 Treatment aim to stabilize the circulation, stop ongoing bleeding and prevent re-bleeding,
includes :

 Fluid replacement (with blood transfusion if needed)

 Prompt endoscopy, with endoscopic haemostasis if necessary
 Surgery, if bleeding cannot be controlled by the above measures
Risk stratification of peptic ulcer bleeding

 Admission Rockall Score

 Full Rockall Score

 Glasgow-Blatchford Bleeding Score

 AIMS65
Rockall risk scoring system

Score < 3 : Good prognosis

Score > 8 : High risk

mortality
Glasgow-Blatchford bleeding score

To assess the likelihood that a patient with an acute UGIB will

need to have medical intervention such as blood transfusion or
endoscopic intervention

Scores > 6 were associated with

>50% risk of needing an intervention

Blatchford O, Murray WR, Blatchford M. A risk score to predict need for

treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318–21
AIMS65

 Age < 65
 Albumin < 3.0 g/dL
 INR > 1.5
 Altered mental status
 SBP < 90 mmHg

Preditcs inpatient mortality, length of hospital stay and cost, but does not estimate need for
intervention in acute UGIB related hospitalisation.
Treating Peptic ulcer bleeding

 Endoscopic hemostasis
 Single or combination therapy.
 Adrenaline injection + Heater probe/Hemoclip
 Surgery , if bleeding cannot be controlled

 Potent acid suppression

Timing of endoscopy

 As early as within 12 hour for UGIB of unknown or high risk

 Within 24 hour may not be harmful if Rockall/ GB score is low enough

 Early endoscopy (within 24 hour)

 Very early endoscopy (within 12 hour) : No benefit on RCT

 Endoscopy within 12 hour, a lower mortality in selected high risk patients; GBS > 12
 Variceal bleeding : within 12 hour

Lim LG et al Endoscopy 2011;43 300.6

Garcia-Tsao G et al. Hepatology 2007,46.922.38
Predictors of Recurrent Bleeding after
Endoscopic Hemostatic Treatment

Elmunzer BJ et al. AM J Gasteroenterol 2008;m103:2625-32

If the patient develops significant UGIB while
on aspirin alone

 Endoscopic hemostasis
 Intravenous infusion of high-dose PPI for 3 days followed by oral PPI
 Withhold aspirin for 3 days; highest risk of rebleeding during first 72 hours
 Resume aspirin on day 4/5 : Antiplatelet effect of aspirin lasts for 5 days after the last
dose
 Avoid prolonged discontinuation of aspirin
 If the patient develops significant UGIB while
on dual antiplatelet therapy

 Endoscopic hemostasis
 Start infusion of high dose PPI
 Withhold clopidogrel for up to 5 days, because stent thrombosis occurs as early as day 7
 Continue aspirin especially if : < 30 days of any stent placement , < 6 months of drug-
eluting stent
 If stopping both antiplatelet drugs is deemed necessary, withhold them for < 3 days.
High risk of stent thrombosis
Lower rebleeding risk after 3 days

P/S : There are many new generation of anti-platelet agents (Prasugrel, Ticagrelor, P2Y12 receptor, Abciximab, Eptifibatide, GPIIb-IIa
DOAC : Rivaroxaban, Dabigatran and Apixaban
Acute Variceal Bleeding

Journal of Hepatology 2022 vol.76. 959-974

 6.2 Packed red blood cell transfusions should be performed conservatively, with a target
hemoglobin level between 7-8 g/dL, although transfusion policy in individual patients
should also consider other factors such as cardiovascular disorders, age, hemodynamic
status, and ongoing bleeding

 6.3 Intubation is recommended before endoscopy in patients with altered mental

consciousness and those actively vomiting blood.

 6.4 Extubation should be performed as quickly as possible after endoscopy.

Journal of Hepatology 2022 vol.76. 959-974

 6.5 In suspected variceal bleeding , vasoactive drugs (terlipressin, somatostatin,
octreotide) should be started as soon as possible and continued for 2-5 days

 6.7 Antibiotics prophylaxis is an integral part of therapy for patients with cirrhosis
presenting with UGIB and should be instituted from admission.

 6.10 Malnutrition increases the risk of adverse outcomes in patients with cirrhosis and
acute variceal bleeding (AVB) and oral nutrition should be started as soon as possible.

Journal of Hepatology 2022 vol.76. 959-974

Preventing recurrent variceal haemorrhage
(secondary prophylaxis)

7.8 First-line therapy for prevention of recurrent variceal haemorrhage is the combination of
tradition NSBBs or carvedilol and EVL.

7.9 TIPS is the treatment of choice in patients who rebleed despite traditional NSBBs or
carvedilol and EVL.

Journal of Hepatology 2022 vol.76. 959-974

Endoscopic variceal ligation
MOH CPG Management of acute variceal bleeding May 2007
Acute Lower Gastrointestinal Bleeding

 LGIB ~20% of all cases of GI bleeding

Initial assessment

 Nature and duration of bleeding :

 Hematochezia (maroon or red blood) : rectum, left colon, brisk UGIB
 Malena (black tarry) : caecum, right colon
 Associated symptoms :
 Abdominal pain/ diarrhoea/ altered bowel habits/ weight loss
 Past medical history :
 Prior GI bleeding/ abdominal or vascular surgeries/ peptic ulcer disease/ inflammatory bowel disease/
abdominopelvic radiation therapy
 Physical examination
 Laboratory testing
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