1. Upper GI Bleeding
D Bunting

2. Acute upper GI bleeding
Incidence
per 100, (1995, 1997)
Mortality (overall)
8-14%1-3(includes 2011)
Mortality (peptic ulcer)
5.8% %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):

3. 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%

4. Presentation Haematemesis* Coffee ground vomit Malaena
Rectal bleeding*

5. 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,

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

7. 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) CD

8. 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

9. 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

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

11. 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

12. 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:CD

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

14. 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):
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):

15. Surgery

16. 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)

17. 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
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):
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

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

19. 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):

23. Discussion
When to consider IR
Tranexamic acid
Surgical technique