Gastrointestinal (GI) Bleed

Recognition

Definition (Journal of the Royal College of Physicians of Edinburgh)

• A Gastro-intestinal (GI) bleed is any bleeding from the gastrointestinal tract. GI bleeds can be upper or lower GI bleeds
  • An upper GI bleed (UGIB) is defined anatomically as “bleeding in the upper gastrointestinal tract proximal to the ligament of Treitz” (rcpe) The ligament of Treitz is the suspensory ligament on the duodenum that suspends the duodenal flexure from the retroperitoneum.
  • A lower GI bleed (LGIB) is a bleed occurring below the ligament of Treitz.
• GI bleeds can be medical emergencies and massive blood loss can occur.
  • Massive blood loss is defined as (www.transfusionguidelines.org):
    • The loss of one blood volume within a 24 hour period
    •  50% blood volume loss within 3 hours
    •  A rate of loss of 150 ml per minute

Causes

• UGIB
  • Peptic ulcer
  • Oesophageal varices
  • Oesophagitis
  • Mallory-Weiss tear
  • Coagulopathies
  • Tumours
• LGIB
  • Diverticular disease
  • Colonic angiodysplasia
  • Ischaemic colitis
  • Crohn’s disease
  • Ulcerative colitis
  • Cancer
  • Internal haemorrhoids
  • Anal fissure
  • Polyps

History

If possible, ascertain if patient has:

• Previous admissions with GI bleeds
• Been diagnosed with liver failure
• Had operations or treatment for GI bleeds
• Been taking anticoagulants, Non-Steroidal Anti-Inflammatory Drugs or alcohol
• Any allergies

• Tachypnoea
• Delayed capillary refill time
• Reduced skin turgor
• Hypotensive
• Tachycardic
• Decreased urine output
• Signs of liver disease if associated with liver failure
  • Palmar erythema
  • Liver flap
  • Telangiectasia
  • Ascites
  • Gynaecomastia

Severity

 

UGIB

• Graded using two Severity Scores
  • Glasgow Blatchford Score
    • This score estimates the risk of a patient requiring intervention, such as transfusion or endoscopy. A patient with a score of 0 is low risk and a patient with a score of 23 is extremely high risk
  • Rockall Score
    • This score estimates the risk of rebleeding or death in patients with upper GI bleed. A score of 0 is a low risk patient and 7 is an extremely high-risk patient

GLASGOW BLATCHFORD SCORE (GBS) (MDcalc)

Blood urea (mmol/L)	<6.5 6.5-7.9 8.0-9.9 10-24.9 ≥25		0 2 3 4 6
Heamoglobin (g/dL)	Men >13 12-12.9 10-11.9 <10	Women >12 10-11.9   <10	0 1 3 6
SBP(mmHg)	>110 100-109 90-99 <90		0 1 2 3
Other markers	Pulse(bpm)   Melaena   Syncope   Hepatic Disease   Cardiac Failure	<100 ≥100 Absent Present Absent Present Absent Present Absent Present	0 1 0 1 0 2 0 2 0 2

ROCKALL SCORE(MD calc)

Age	<60 61-79 ≥80	0 +1 +2
Shock	Pulse<100 bpm, SBP>100 mmHg Pulse>100 bpm, SBP>100 mmHg Pulse>100 bpm, SBP<100 mmHg	0 +1 +2
Co-morbidities	No major co-morbidities Cardiac failure, IHD, any other major co-morbidity Renal or liver failure, disseminated malignancy	0 +2 +3

LGIB

• The Oakland Score
  • This score is used to predict whether it is safe to discharge a patient with a lower GI Bleed. 0 points gives a 99% probability of safe discharge whereas a score of 35 gives a 0-1% probability of safe discharge

OAKLAND SCORE (MDcalc)

Age, years	<40 40-69 ≥70	0 +1 +2
Sex	Female Male	0 +1
Previous lower GI bleeding admission	No Yes	0 +1
PR findings	No Blood Blood	0 +1
Heart rate, bpm	<70 70-89 90-109 ≥110	0 +1 +2 +3
Systolic blood pressure, mmHg	50-89 90-119 120-129 130-159 ≥160	+5 +4 +3 +2 0
Heamoglobin g/dL	36-69 70-89 90-109 110-129 130-159 ≥160	+22 +17 +13 +8 +4 0

 

Initial Assessment and Investigations

• ABCDE assessment
• Assess patient’s airway - if vomiting and drowsy place in recovery position
• Monitor oxygen saturations and respiratory rate
  • If patient is hypoxic give Oxygen (O₂) to achieve target saturations. Initially give 15 L/min via a reservoir mask if the patient is acutely unwell
  • If vomiting use nasal cannula
• Target saturations:
  • 94 - 98% for patients not at risk of hypercapnic respiratory failure
  • 88 - 92% for patients at risk of hypercapnic respiratory failure due to conditions such as Chronic Obstructive Pulmonary Disease (COPD)
• Examine patient’s chest. If the patient is vomiting there is a risk of aspiration
• Arterial blood gas (ABG) if concerned about patient’s ventilation
• Obtain intravenous access by placing 2 large bore cannulae in the antecubital fossa. Take blood to check Full Blood Count (FBC), Urea and Electrolytes (U&Es), Liver Function Tests (LFTS), Venous blood gas (VBG), Clotting, Group and Save or Cross Match of 4 – 6 units
• Check Capillary Refill Time (CRT) - hold for five seconds and refilling should occur in 3 seconds
• Assess pulse rate, rhythm and character
  • If no pulse present start advanced life support
• Monitor heart rate and blood pressure
• Listen to patient’s heart sounds
• Call for senior help if not already done
• Check urine output and consider catheterisation
• Fluid resuscitation
  • Non-massive haemorrhage
    • Initial fluid resuscitation with crystalloid e.g. 0.9% Sodium Chloride. See more details in the “Circulation” Chapter in the “Response” Section under “Fluid Challenge”
    • Aim to not over fill due to risk of bleeding with increased pressure
  • Massive haemorrhage
    • Initial resuscitation with blood products is preferred
    • If there is no imminent availability of blood components and there is profound hypotension fluid resuscitate the patient with crystalloid e.g. 0.9% Sodium Chloride
    • Initiate Massive Haemorrhage Protocol by calling the blood bank
      • This contains four units of Packed Red Blood Cells (RBC) and four units of Fresh Frozen Plasma (FFP)
      • Transfuse in a ratio of 1:1, that is 1 dose (4 units) of packed RBC to 1 dose (4 units) of FFP
      • In extreme situations emergency O negative blood may be used. Group specific RBC should be given at the earliest possible opportunity
    • Correct any clotting abnormalities
    • Consider tranexamic acid in trauma pages
    • If there is any suspicion of the bleed originating from a varices then the patient will require antibiotics and terlipressin
• 12 lead Electrocardiogram (ECG)
• Withhold precipitant factors and consider risk-benefit ratio with regards to continuing anticoagulants and antiplatelets
• Keep patient nil by mouth
• Prevent hypothermia
• Identify underlying cause and treat where possible
• Check pupils are equal and reactive
• Assess Glasgow Coma Scale or ACVPU using the NEWS2 chart
• Check patient’s temperature and blood sugar
• Examine patient’s abdomen and legs
• Discuss venous thromboembolism prophylaxis with senior as it is unlikely that this will be required

Response

UGIB

 

Immediate management

• Assess if any of the following are present:
  • Ongoing bleeding
  • Suspected variceal bleed
  • Unstable episode requiring transfusion
  • Lost ≥30% blood volume
• If you answer yes to any of these, an urgent oesophago-gastro-duodenoscopy (OGD) is required once the patient is adequately resuscitated
• If all the answers are no then the patient should be admitted and an OGD done within 24 hours

Referrals

• Contact senior in your team
• Contact critical care outreach team
• Referral to gastroenterologists
• Consider referral to Intensive Care Unit (ICU) if:
  • Haematemesis as patient will need airway support for OGD
  • Failure to respond to medical management
  • Patient requires ventilator support
  • Patient requires blood pressure support
  • Deterioration of blood gas following medical management

LGIB

 

Immediate management

• If large lower GI bleed patient needs emergency CT angiogram with embolization
• Colonoscopy
• Patient is likely to also require OGD to rule out upper GI bleed

Referrals

• Contact senior in your team
• Contact critical care outreach team
• Referral to gastroenterologists
• Referral to ICU should be consider in patients with:
  • Failure to respond to medical management
  • Patients requiring ventilator support

Future management

• Review by gastroenterologists regarding future management