Matt Warren. Gastroenterology North Tyneside Hospital This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. GI Bleeding Matt Warren. Gastroenterology North Tyneside Hospital

Clinical Scenario Call from A&E middle grade This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Clinical Scenario Call from A&E middle grade Known varices – haematemesis BP 85/42, pulse 43 (beta-blocked) Have d/w Medical team “get an urgent endoscopy” Thoughts?

Introduction Common GI emergency Incidence 50 – 190 / 100 000 year This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Introduction Common GI emergency Incidence 50 – 190 / 100 000 year 50-70 000 admissions per year Overall mortality 7% Mortality in IP 30% Mortality hasn’t really changed but this reflects the fact that patients are older and sicker

Causes of UGI Bleed Peptic ulcer 35% Erosions 8-15% Oesophagitis 5-15% This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Causes of UGI Bleed Peptic ulcer 35% Erosions 8-15% Oesophagitis 5-15% Varices 12 % MW Tear 15% Malignancy 1%

Emergency Treatment Variable Endoscopy rota Endoscopist experience This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Emergency Treatment Variable Endoscopy rota Endoscopist experience 30% unable to manage variceal bleed Interventional radiology / Surgery

What can you do? Make diagnosis Assess severity Resuscitate Treat This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. What can you do? Make diagnosis Assess severity Resuscitate Treat

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. By the end… Guidelines Confident in pre-endoscopy diagnosis and management Considered some grey / difficult areas Questions

But not…. Basics of resuscitation! Endoscopic management This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. But not…. Basics of resuscitation! Endoscopic management Lots of boring trials

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Patient 54 year old – A&E Moderate haematemesis This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Patient 54 year old – A&E Moderate haematemesis Called to assess by A&E ABC – done. Approach….

1. Make a diagnosis / assess severity This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. 1. Make a diagnosis / assess severity Cause of bleeding Variceal or Non-variceal (85% +) ? High risk or low risk Rockall or Blatchford Varices automatically high risk

Task 1 Pairs Features that would make you suspect varices…. This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Task 1 Pairs Features that would make you suspect varices….

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Variceal Indicators Known varices… Known cirrhosis with PHT This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Variceal Indicators Known varices… Known cirrhosis with PHT Stigmata advanced liver disease Jaundice Ascites Encephalopathy

Patient No indicators of varices. Should you admit? This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Patient No indicators of varices. Should you admit? How will you decide?

Task 2 Do you admit all GI bleeders? This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Task 2 Do you admit all GI bleeders? How would you decide who to send home?

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NICE Recommends! Non-variceal (MW tear) low risk bleed This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. NICE Recommends! Non-variceal (MW tear) low risk bleed Could send home for OP OGD / No OGD

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. 16% of patients had score 0 – Lancet 2009

We admit our patient Resuscitate as normal This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. We admit our patient Resuscitate as normal Hb 8.4, Platelets 47, WCC 6.5 U&E normal, LFT normal Any other bloods you’d like?

Patient Resuscitate as normal Hb 8.4, Platelets 47, WCC 6.5, This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Patient Resuscitate as normal Hb 8.4, Platelets 47, WCC 6.5, U&E normal, LFT normal Fib 0.8, INR 1.3

Task 3 Will you transfuse? Blood Platelets FFP This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Task 3 Will you transfuse? Blood Platelets FFP

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This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. NICE Recommends! (2)

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. NICE Recommends (3)

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. NICE recommends! (4)

Patient revisited… Resuscitate as normal This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Patient revisited… Resuscitate as normal Hb 8.4, Platelets 47, WCC 6.5, U&E normal, LFT normal Fib 0.8, INR 1.3 Nothing if stable MTP protocol if massive bleed FFP, Platelets if bleeds

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Some drugs……? You’ve made a diagnosis You’ve resuscitated / transfused This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Some drugs……? You’ve made a diagnosis You’ve resuscitated / transfused You want to give some drugs!

Task 4 – what pre-endoscopy drugs do you give for… This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Task 4 – what pre-endoscopy drugs do you give for… Non-variceal Bleed? Suspected variceal?

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NICE Recommends! (4) IMPORTANT! Concerns or contra-indications? This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. NICE Recommends! (4) IMPORTANT! Concerns or contra-indications?

NICE Recommends! (5) What…Never? This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. NICE Recommends! (5) What…Never? Are there any circumstances you would? High Rockall score? Delay to endoscopy? Unit policy?

So… Assessed varices vs. Non-variceal This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. So… Assessed varices vs. Non-variceal Stratified risk – early discharge Resuscitate / blood products Drugs esp. suspected varices Questions?

Case 1 27 year old male Binge of alcohol Haematemesis yesterday This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Case 1 27 year old male Binge of alcohol Haematemesis yesterday All bloods, exam and obs normal Diagnosis? Admit? Drugs? Endoscopy?

Case 2 88 IP on COTE – CCF Coffee ground vomit – witnessed This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Case 2 88 IP on COTE – CCF Coffee ground vomit – witnessed Tachy – normal BP Bloods normal Concerned?

Case 3 – 4am IP, 44yrs - # NOF after fall This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Case 3 – 4am IP, 44yrs - # NOF after fall Aspirin / Clopidogrel for stent 3/52 ago Alc ++ (no stigmata CLD, bloods normal) Haematemesis – stable BP, Tachy Diagnosis? Severity? Drugs? Scope?

Case 3 – NICE Recommends! Stop all (inc NSAID) in acute situation This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Case 3 – NICE Recommends! Stop all (inc NSAID) in acute situation Restart aspirin ASAP following haemostasis Secondary prevention

Timing of endoscopy Out of hours High risk score This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Timing of endoscopy Out of hours High risk score Unstable despite resuscitation Suspected varices

Case 4 Known cirrhotic / varices This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Case 4 Known cirrhotic / varices Massive GI bleed – unstable. GCS 12/15 INR 1.9, platelets 34, Fib 0.7 Diagnosis? Treatment? Endoscopy? Take a minute on this one….

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Varices! ABC Terlipressin and Tazocin MTP / blood products This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Varices! ABC Protect the airway Terlipressin and Tazocin MTP / blood products May be little point scoping…

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Tamponade

Tamponade Should control bleeding in 90% This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Tamponade Should control bleeding in 90% Majority will rebleed within 24 hrs of removal Bridge to endoscopy Protect airway Read the manual!

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Conclusions Make a diagnosis Stratify risk and respond This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Conclusions Make a diagnosis Stratify risk and respond Start new drugs / stop (or not) others Measure / correct clotting Transfuse if needed Refer when appropriate for OGD Not as initial knee-jerk reaction!

This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License. Questions?