1. Click to edit Master subtitle style Acute GI Bleeds Miles Allison Department of Gastroenterology and Hepatology Aneurin Bevan University LHB

2. Click to edit Master text styles Second level Third level Fourth level Fifth level Anythingfrompersistingooze……….. 22 units over 5 weeks

3. ..to life thre ateni ng varic eal blee ding!

4. Click to edit Master text styles Second level Third level Fourth level Fifth level Factsandfigures Commonest emergency encountered by gastroenterologists Approx. 60,000 admissions per year Peptic ulcer accounts for 36% Approx. 6,000 deaths per year Mortality 7% in new admissions and 26% in established inpatients Hearnshaw: BSG 2008

5. Click to edit Master text styles Second level Third level Fourth level Fifth level KeypadQuestion1

6. Click to edit Master text styles Second level Third level Fourth level Fifth level Scotland: 30-day mortality by year 2000- 10 Courtesy Dr John Morris

7. Click to edit Master text styles Second level Third level Fourth level Fifth level Issues todiscuss Risk scoring Early discharge Tips at endoscopy Place of proton pump inhibitors Rescue therapy Out-of-hours

8. Click to edit Master text styles Second level Third level Fourth level Fifth level Issues todiscuss Risk scoring: Glasgow Blatchford Score: Early discharge Tips at endoscopy Place of proton pump inhibitors Rescue therapy Out-of-hours Glasgow-Blatchford Score Blood Urea (mmol/L) 6.5-8.02 8.0-10.03 10.0-254 >256 Haemoglobin (g/L) for men 12.0-12.91 10.0-11.93 <10.06 Haemoglobin (g/L) for women 10.0-11.91 <10.06 Systolic blood pressure (mm Hg) 100–1091 90–992 <903 Other markers Pulse ≥100 (per min)1 Presentation with melaena1 Presentation with syncope2 Hepatic disease2 Cardiac failure2

9. Click to edit Master text styles Second level Third level Fourth level Fifth level GlasgowBlatchfordscore Score 0-1: very low risk Better ROC than Rockall for prediction of death or the need for intervention SIGN recommend Rockall scoring

10. Click to edit Master text styles Second level Third level Fourth level Fifth level Initialmanagement Resuscitation Stop NSAIDs Care re stopping antiplatelet drugs SIGN recommend transfuse if loss of >30% circulating volume

11. Click to edit Master text styles Second level Third level Fourth level Fifth level Initialmanagement Resuscitation Stop NSAIDs Care re stopping antiplatelet drugs (consider early restart of anticoagulants SIGN recommend transfuse if loss of >30% circulating volume Restrictive versus liberal transfusion policy….

12. Click to edit Master text styles Second level Third level Fourth level Fifth level Keypadquestion2:

13. Click to edit Master text styles Second level Third level Fourth level Fifth level Restrictive vsLiberaltransfusion Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013 Jan 3;368(1):11-21 Liberal (transfuse up to 100g/l) vs. restrictive strategy (up to 80g/l). Patients with heart disease were excluded. Outcomes were better among patients randomised to the restrictive strategy. Rebleeding 10% vs 16% (p=0.01) Survival at 6 weeks 95% vs 91%

14. Click to edit Master text styles Second level Third level Fourth level Fifth level Timingofgastroscopy Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding

15. StigmataofBleedingRisksof Re-bleedingandPrevalence

16. Indications forendoscopictherapy

17. Click to edit Master text styles Second level Third level Fourth level Fifth level Endoscopictherapy Injection Heater probe Gold probe Gold injection probe Argon plasma coagulation Clips Occasionally banding

18. Click to edit Master text styles Second level Third level Fourth level Fifth level Endoscopictherapy Injection Heater probe Gold probe Gold injection probe Argon plasma coagulation Clips Occasionally banding ………and the new kid on the block……….

19. Directhaemostaticsprays!

20. Click to edit Master text styles Second level Third level Fourth level Fifth level Sentinelclot

21. Click to edit Master text styles Second level Third level Fourth level Fifth level Injectiontherapy Simple Epinephrine 1:10000 – 1:100000 Safe Best if followed by another method Beware in coagulopathy/severe thrombocytopenia

22. Click to edit Master text styles Second level Third level Fourth level Fifth level PredictorsofmortalityinbleedingPU 9032 patients High risk features, elderly/co-morbidities, haematemesis and/or shock at presentation, in-hopsital bleeding, rebleeding, need for surgery H. pylori ulcers had lower mortality Chiu et al; CGH 2008

23. Click to edit Master text styles Second level Third level Fourth level Fifth level Optimisingconditions Scope in theatre if difficult to resuscitate Surgical team on standby if heavy non-variceal bleed suspected Choice of gastroscope Erythromycin? (ESGE recommendation 250mg i.v. 30-120min prior) Value of changing position Plastic cap

26. Click to edit Master text styles Second level Third level Fourth level Fifth level Indications forsecondlookendoscopy Unsure of site of bleeding on initial gastroscopy Uncertain re success of first intervention Clinical possibility of rebleed <24hr Possible Dieulafoy

27. Click to edit Master text styles Second level Third level Fourth level Fifth level Indications forsecondlookendoscopy Unsure of site of bleeding on initial gastroscopy Uncertain re success of first intervention Clinical possibility of rebleed <24hr Possible Dieulafoy Not routinely necessary and may depend on confidence of endoscopist

28. Click to edit Master text styles Second level Third level Fourth level Fifth level Keypadquestion3

29. Click to edit Master text styles Second level Third level Fourth level Fifth level Afewpoints revaricealbleeding Oesophageal versus gastric varices Banding (not injection) for BOV, but glue/lipiodol for GV Start terlipressin and antibiotics early Sengstaken tube can still be life saving Importance of maintaining safe airway Trans-jugular intrahepatic porto-systemic shunting if not at risk of encephalopathy Prognosis depends on Child Pugh score

30. Click to edit Master text styles Second level Third level Fourth level Fifth level Varicealbanding

31. Click to edit Master text styles Second level Third level Fourth level Fifth level Rarer causes Haemobilia GIST Stomal ulcerDieulafoy Courtesy N Hawkes and R Tighe G.I.S.T.

32. Click to edit Master text styles Second level Third level Fourth level Fifth level PPIinfusion After endotherapy Omeprazole 80mg iv, then 8mg/hr for 72hr Rebleed in 7% vs 23% Five in omeprazole group died within 30 days vs 12 in placebo group (p=0.13) Lau : NEJM 2000

33. Click to edit Master text styles Second level Third level Fourth level Fifth level Rescuetherapy Repeat gastroscopy Angiography/embolisation Surgery (post-operative mortality 30%)

34. Click to edit Master text styles Second level Third level Fourth level Fifth level Oct obe r 201 1 81 years Right sided arm and leg weakness CT head normal Suddenly became hypotensive, hypovolemic and anaemic (P > 100, BP < 100 6 units transfused in 2 hours) CT angiogram

35. Click to edit Master text styles Second level Third level Fourth level Fifth level CT Ang iogr am Axial, coronal and sagittal reformatted showed active bleeding from one of the branch of the Gastroduodenal artery- the inferior pancreatico-duodenal arcade.

36. Click to edit Master text styles Second level Third level Fourth level Fifth level Ang iogr am Excellent correlation of the CT to the angiogram which made it easy to access the bleeding artery with a micro-catheter, which was embolised with glue.

37. Click to edit Master text styles Second level Third level Fourth level Fifth level ArterialEmbolisationvsSurgery 8 year experience from Uppsala 40 rebleeds treated by AE and 51 by surgery 1 death in AE group vs 7 following rescue surgery Eriksson: J Vasc Interv Radiol 2008

38. Click to edit Master text styles Second level Third level Fourth level Fifth level NCEPOD 2015 Patients with AUGIB should be admitted or transferred only to hospitals with: 24/7 access to on-site endoscopy and surgery Interventional radiology must be available on site or within a formal network

39. Click to edit Master text styles Second level Third level Fourth level Fifth level NCEPOD 2015 Patients with AUGIB should be admitted or transferred only to hospitals with: 24/7 access to on-site endoscopy and surgery Interventional radiology must be available on site or within a formal network Patients should be looked after by a consultant with a special interest The artificial “turf” division between medicine (upper) and surgery (lower) should be removed

40. Click to edit Master text styles Second level Third level Fourth level Fifth level 30-daymortality:Monday-Friday vs Weekend p<0.05

41. Click to edit Master text styles Second level Third level Fourth level Fifth level 30-daymortality:Monday-Friday vs Weekend p<0.05 v

42. Click to edit Master text styles Second level Third level Fourth level Fifth level Outofhours Clinical networks Smaller and larger hospitals Transfer to larger hospitals with Endoscopist and support nurse rotas At least 8 experienced endoscopists on rota, who can pre-assess patients Full range of interventional radiology including mesenteric angiography and TIPS

43. Click to edit Master text styles Second level Third level Fourth level Fifth level Outofhours:BSG-NHSEnglandSurvey2013

44. Click to edit Master text styles Second level Third level Fourth level Fifth level WhereshouldpatientswithsignificantGIbleedingbemanaged? HDU Dedicated GI bleeding ward/bay Importance of handover

45. Click to edit Master text styles Second level Third level Fourth level Fifth level Summary:commonpitfalls Wrong time Wrong place Wrong person Inadequate support Failure to hand over

46. Click to edit Master text styles Second level Third level Fourth level Fifth level Importanceofteamwork

47. Click to edit Master text styles Second level Third level Fourth level Fifth level Importance of teamwork …………and remember: all bleeding stops eventually!