Upper GI Bleeding D Bunting

Acute upper GI bleeding Incidence 103-172 per 100,0001-2 (1995, 1997) Mortality (overall) 8-14%1-3(includes 2011) Mortality (peptic ulcer) 5.8%3 - 8.8%1 30% postoperative3 1. T.A. Rockall, R.F.A. Logan, H.B. Devlin, et al.: Incidence of and mortality from acute upper gastrointestinal hemorrhage in the United Kingdom. Br Med J. 311(6999), 1995, 222. 2. O. Blatchford, L.A. Davidson, W.R. Murray, et al.: Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. Br Med J. 315(7107), 1997, 510. 3. S.A. Hearnshaw, R.F. Logan, D Lowe, et al. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut 2011;60(10):1327-35.

Aetiology Peptic ulcer 35% Oesophagitis 24% Gastritis/erosions 22% Nil seen 17% Erosive duodenitis 13% Varices 11% Mallory-Weiss tear 4.3% Malignancy 3.7% Others 2.6%

Presentation Haematemesis* Coffee ground vomit Malaena Rectal bleeding*

Scoring systems Rockall5 Glasgow Blatchford Score2 Age Shock Comorbidity Diagnosis Stigmata of recent haemorrhage Glasgow Blatchford Score2 Better in predicting low risk Urea, Hb, BP, HR, comorbidity, presentation type 2. O. Blatchford, L.A. Davidson, W.R. Murray, et al.: Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. Br Med J. 315(7107), 1997, 510. 5. T.A. Rockall, R.F.A. Logan, H.B. Devlin, et al.: Variation in outcome after acute upper gastrointestinal hemorrhage. Lancet. 346(8971), 1995, 346-50.

Initial management Admit Resuscitation Endoscopy Emergency (ongoing bleeding) Urgent (<24hr) Determine risk of re-bleeding Therapy

Initial management PPI therapy (pre-endoscopy) Cochrane review6 stigmata of recent haemorrhage and hence endoscopic therapy but no reduction in mortality, re-bleeding rate or need for surgery Somatostatin, octreotide, vasopressin No evidence (except suspected varices) 6. Sreedharan A, Martin J, Leontiadis GI, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010;(7) CD005415.

Endoscopy Specialist endoscope Anaesthetic support Intubation if obtunded/unstable Over-tube and lavage Gastric ulcers Incisura, antrum, high lesser curve Duodenal ulcer Posterior, size and active bleeding determine risk of therapeutic failure

Endoscopic treatments Good evidence Active bleeding or non-bleeding vessel = therapy Injection (adrenaline) Thermal Heater probe Non-contact (APC) Mechanical Clips Band ligation Chemical Thrombin Fibrin

Endoscopic treatments Combination therapy Adrenaline alone not advised 2nd look endoscopy Questionable benefit over best treatment

PPI therapy Hong Kong Group7 Cochrane review8 3 days high dose infusion omeprazole 80mg, 8mg/hr Reduction in re-bleeding 22.5% to 6.7%. Cochrane review8 Re-bleeding 17.3% vs 10.6% Surgery 9.3% vs 6.1% Reduction in mortality in high-risk 7. Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Eng J Med 2000;343(5):310-6 8. Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev 2006;(1):CD002094

Tranexamic acid Cochrane review HALT IT Mortality benefit No benefit in bleeding, surgery or transfusion requirement No beneficial effect when only studies using PPIs included Not currently recommended HALT IT Haemorrhage ALleviation with Tranexamic acid – InTestinal system Plan for 8000 patients randomised *Tranexamic acid for upper gastrointestinal bleeding. Gluud LL, Klingenberg SL, Langholz E, Cochrane Database Syst Rev. 2012;1:CD006640.

Surgery Failure of endoscopic treatment Postoperative mortality 30% ? Management in high risk of re-bleeding with initial success? Procedure Under-running & PPI Resection Vagotomy

Surgery RCTs Under-running & H2 blocker vs. vagotomy/partial gastrectomy9 Terminated due to high rate of fatal re-bleeding in minimal surgery group 6 of 62 vs 0 of 67 Under-running & vagotomy vs. partial gastrectomy10 17% vs 3 % re-bleeding 22% vs 23% mortality 9. Poxon VA, Keighley MR, Dykes PW, et al. Comparison of minimal and conventional surgery in patients with bleeding peptic ulcer: a multicentre trial. Br J Surg 1991;78(11):1344-5. 10. Millat B, Hay JM, Valleur P et al. Emergency surgical treatment for bleeding duodenal ulcer: oversewing plus vagotomy verus gastric resection, a controlled randomized trial. French Associations for Surgical Research. World J Surg 1993;17(5):568-74.

Surgery

Management of recurrent bleeding Endoscopic re-treatment vs surgery* Fewer complications Successful cessation of bleeding in 75% But 2cm ulcers with shock less likely to respond Selective approach Angioembolisation Superselective coiling Success rate 64-91% Mortality 5-25% * Lau JY, Sung JJ, Lam YH, et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Eng J Med 1999;340 (10) 751-6.

Angioembolisation 2 retrospective comparative studies Honk Kong 201111 Re-bleeding higher with angio Complications higher in surgical group Mortality similar, 25% angio and 30% surgery Sweden 200812 Mortality 3% vs 14% ns Procedure of choice in re-bleeding after surgery 11. Wong TC, Wong KT, Chiu PW, et al. A comparison of angiographic embolization with surgery after failed endoscopic haemostasis to bleeding peptic ulcers. Gastrointestinal Endosc 2011; 73(5): 900-8. 12. Eriksson LG, Ljungdahl M Sundom M et al. Transcatheter arterial embolisation versus surgery in the treatment of upper gastrointestinal bleeding after therapeutic endoscopy failure. J Vasc Interv Radiol 2008;19(10):1413-8

Angioembolisation Failure of endoscopic control Angio vs surgery for re-bleeding after surgery Angio vs waiting in high-risk patients Local availability Patient condition

Helicobacter Pylori Cochrane review13 Eradication reduces risk of re-bleeding 5.6% vs 2.9% 13. Gisbert et al. Meta-analysis: Helicobacter pylori eradication therapy vs. anti-secretory non-eradication therapy for the prevention of recurrent bleeding from peptic ulcer. Aliment Pharmacol Ther 2004;19(6):617-29.

Discussion When to consider IR Tranexamic acid Surgical technique