Transcript Management of a Pt with Hematemesis

Dr. Salem Mohammad Bazarah
MD, M.Ed, FACP, FRCPC, FRCPC (GI) & PhD
MANAGEMENT OF A PT WITH
HEMATEMESIS
A common medical condition
 250,000 – 500,000 admissions/year US
 UGI bleeding incidence 100/100,000 adults
 Incidence increases 20-30 fold from third to ninth
decade of life
 LGI bleeding incidence 20/100,000 adults
 Overwhelmingly disease of the elderly
 GI bleeding stops spontaneously in 80 %
Morbidity Data
 Majority will receive blood transfusions
 2 – 10 % require urgent surgery to arrest
bleeding
 Average LOS 4 – 7 days
 Mortality rates for UGI bleeding 2 – 15 %
 Mortality for patients who develop bleeding
after admission to hospital for another reason
is 20 – 30 %
Costs
 Average hospital costs exceed $ 5,000 per
admission
 Most of this for hospital bed and ICU stays
rather than physician fees, blood products,
diagnostic tests, or medications
 Reduction of hospital admissions and LOS
has greatest potential to reduce costs
UGI bleeding:Nomenclature
 Hematemesis 25 %
 Melena alone 25 %, 50 – 100 cc of blood will
render stool melenic
 Hematochezia 15 %, seen in massive UGI
hemorrhage
 “Red blood” hematemesis
 “Coffee ground” emesis
Indications for Hospitalization
and Intensive Care
 Traditional: Endoscopy on the day of
admission or on the day after
 Recent studies: Complete endoscopic risk
stratification PRIOR to admission
 Between 25- 30 % of patients with UGI
bleeding could be discharged from the
Emergency Department
Predictors of Outcome in UGI
bleeding
Clinical
Endoscopic
Age > 60 y
Low risk endoscopic
findings
Hemodynamic instability
High risk endoscopic
findings
Comorbidities
Hematemesis (red blood)
Coagulopathy
Ulcer Appearance and
Prognosis
Appearance
Prevalence %
Rebleed % Mortality %
Clean base
42
5
2
Flat spot
20
10
3
Clot
17
22
7
Visible vessel
17
43
11
Active bleeding
18
55
11
History
 45 yrs male with 1 day hx of vomiting blood
Approach
 Assess the severity
 Resuscitate
 Establish the site of bleeding
 Endoscopic intervention
 Reassess severity: liase with surgical team
 Medical treatment
 Indications for surgery
Assessing severity: Rockall
criteria
Criterion
 Age
Score
<60 years
60-79 yrs
>80 years
 Shock
None
Pulse & sBP >100
sBP <100
 Co-morbidity
None
Cardiac/any major
Renal/liver/malig.
 Total initial score
0
1
2
(max = 7)
0
1
2
0
2
3
Implications of initial
score
Initial risk score (pre-endoscopy)
Score Mortality
0
0.2%
1
2.4%
2
5.6%
3
11.0%
4
24.6%
5
39.6%
6
48.9%
7
50.0%
Rockall TA et al Gut 1996; 38: 316-21
Resuscitate
 Large bore intravenous cannula x 2
 X-match 4 units, give colloid & transfuse if
 Fresh melaena on PR
 Postural hypotension >15mm/Hg
 sBP <100mmHg
 Cross match 6 units for
 Suspected variceal bleeding
 Otherwise group and save serum only
Resuscitation
 Indications for CVP
 Rockall score > 3, first rebleed, or inadequate access
 Insert urinary catheter if CVP appropriate
 Urea/creatinine ratio
 If >unity (eg 12.4/90), then upper GI bleed likely
 Monitor Pulse & BP ‘?hrly’
 Guide of halves: if pulse higher or BP lower than last
recording, then halve the time to the next recording
 If pulse trend rises on 3 occasions, call senior cover
Establish site of bleeding
 Endoscopy on next available list
 Ideally <24hr
 Out of hours endoscopy
 If a surgical decision depends on the result
 Therefore consent ‘endoscopy, ?proceed’
 Check endoscopy report for
 stigmata of recent haemorrhage
 intervention
Stigmata of recent
haemorrhage
 Clean ulcer base (rebleed <1%)
 Black spots ulcer base (rebleed
5%)
Stigmata of recent haemorrhage
 Fresh clot (rebleed 30%)
 Visible vessel (rebleed 50%)
Stigmata of recent haemorrhage
 Bleeding vessel (rebleed 80%)
Upper GI Bleeding
Klaus Gottlieb, MD, FACP, FACG
Source of bleeding
Common
Uncommon/Rare
 DU (35%)
 Varices
 GU (20%)
 Tumour
 Oesophagitis (6%)
 Aortoenteric fistula
 Mallory-Weiss (6%)
 Dieulafoy
 No source found (20%)
 Haemobilia
 Angiodysplasia
Intervention
 Endoscopic injection with
 Adrenaline 1:10 000, thrombin, sclerosant, or saline all halve
the risk of rebleeding
 As good as heater probe, laser therapy
 Tranexamic acid
 1g iv three times daily for 72hr reduces mortality
 Omeprazole 60mg iv stat and infusion 8mg/hr for 72hr
 may reduce mortality after endoscopic intervention
 Nothing else has been shown to work
Do not prescribe iv ranitidine, or oral PPI
after endoscopy
until
Reassess severity: update
Rockall
Score
 Endoscopic diagnosis
 No lesion, or M-W tear
 All other diagnoses
 Malignancy of upper GI tract
 Stigmata of recent haemorrhage
 None/haematin
 Clot, visible vessel,blood in stomach
 Final score after endoscopy
11)
0
1
2
0
2
(max
Updated Rockall score
Initial score (preendoscopy)
Score Mortality
0
0.2%
1
2.4%
2
5.6%
3
11.0%
4
24.6%
5
39.6%
6
48.9%
7
50.0%
Final score (after
endoscopy)
Score Mortality
0
0%
1
0%
2
0.2%
3
2.9%
4
5.3%
5
10.8%
6
27.0%
7
17.3
8+
41.1%
Further management
 Liase with surgeons if
 Initial score >3 (ie if CVP necessary)
 Posterior duodenal ulcer
 Final Rockall score >4
 After endoscopy
 Eat & drink if no stigmata, or haematin only
 Clear fluids for 12 hr if endoscopic intervention
 NBM only if haemostasis not secure (varices)
 Re-examine after 4-8hr for signs rebleeding
 Ring blood bank to keep blood available for 24hr
after endoscopic intervention
Signs of rebleeding
 Rise in pulse rate
 Fall in CVP
 Decrease in hourly urine output
 Further haematemesis or fresh melaena
 Look at the patient as well as the charts!
 Act if rebleeding suspected
 FBC and transfuse
 Ensure large bore access, central line and catheter
 Call surgical team
Indications for surgery
 Early surgery (esp. elderly) assoc. with lower mortality
 Age over 60 years
 Transfusion >4 units in 24hr
 One rebleed
 Continued bleeding
 Age under 60 years
 Transfusion >8 units in 24hr
 Two rebleeds
 Continued bleeding
 Decision not to operate should be taken by consultant
Special notes - Variceal
bleeding
 Suspect variceal bleeding if…..
- Alcohol Hx
- Deranged LFT’s
- Jaundice*
- Hyponatraemia*
- Ascites*
- Coagulopathy
- Low platelets
- Previous Hx of varices*
Special notes – Variceal
Bleeding





Resuscitate
Correct coagulopathy (FFP x 4 and vit K IV)
Endoscopy and banding/sclerotherapy
Glypressin 2mg iv stat and 1-2mg repeated 4hrly
Treat other aspects of decompensation





Ascites (spironolactone, no N/saline)
Encephalopathy (lactulose, no sedation)
Renal impairment (avoid hypovolaemia)
Malnutrition (iv vitamins, fine bore feeding)
Underlying liver disease (hepatic ‘screen’, aFP etc)
 Post-bleed prophylaxis
Summary
 Objective assessment (Rockall criteria)
 Resuscitation before endoscopy
 Monitor by rule of halves: look for trends
 No role for empirical acid suppression
 Critical appraisal of endoscopy report
 Liaise with surgeons early
 Discriminate between high & low risk patients