This article offers a comprehensive guide to diagnosing and managing acute upper gastrointestinal bleeding. It emphasises timely assessment, tailored treatments, and risk evaluation for optimal patient care. 

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Upper Gastrointestinal Bleeding  (UGIB)

The initial evaluation of patients with acute upper GI bleeding focuses on the assessment of hemodynamic stability and resuscitation if necessary. It is usually followed by endoscopy to diagnose and treat the cause of upper GI bleed.

Diagnosis

1. Bleeding manifestations

Hematemesis (either red blood or coffee-ground emesis) suggests bleeding proximal to the ligament of Treitz. The presence of frankly bloody emesis suggests moderate to severe bleeding that may be ongoing, whereas coffee-ground emesis suggests more limited bleeding.

The majority of melena (black, tarry stool) originates proximal to the ligament of Treitz (90 per cent), though it may also originate from the oropharynx or nasopharynx, small bowel, or colon.

Hematochezia (red or maroon blood in the stool) is usually due to lower GI bleeding. However, it can occur with massive upper GI bleeding, which is typically associated with orthostatic hypotension.

Factors that are predictive of a bleed coming from an upper GI source identified in a meta-analysis included:

• A patient-reported history of melena (likelihood ratio [LR] 5.1-5.9)
• Melanic stool on examination (LR 25)
• Blood or coffee grounds detected during nasogastric lavage (LR 9.6)
• A ratio of blood urea nitrogen to serum creatinine greater than 30 (LR 7.5)

On the other hand, the presence of blood clots in the stool made an upper GI source less likely (LR 0.05). Factors associated with severe bleeding included:

• Red blood detected during nasogastric lavage (LR 3.1)
• Tachycardia (LR 4.9)
• A haemoglobin level of less than 8 g/dL (LR 4.5-6.2)

2. Past medical history

Up to 60 per cent of patients with a history of an upper GI bleed are likely bleeding from the same lesion.

The goal of history taking is also to identify important comorbid conditions that may lead to upper GI bleeding or may influence the patient's subsequent management such as the history of liver, heart or kidney disease, excess alcohol use, NSAIDs/ antithrombotic use, long-standing dyspeptic symptoms, past blood transfusions, prior abdominal surgeries.

3. Symptom assessment

Symptoms that suggest the bleeding is severe include:

• Orthostatic dizziness
• Confusion
• Angina
• Severe palpitations
• Cold/clammy extremities

4. Physical examination

The physical examination is a key component of the assessment of hemodynamic stability. Signs of hypovolemia include :

1. Mild to moderate hypovolemia (less than 15 per cent of blood volume lost): Resting tachycardia.
2. Blood volume loss of at least 15 per cent: Orthostatic hypotension (a decrease in the systolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20 beats per minute when moving from recumbency to standing).
3. Blood volume loss of at least 40 per cent: Supine hypotension.

5. Laboratory data

The initial haemoglobin level in patients with acute upper GI bleeding may be at the patient's baseline because the patient is losing whole blood.

With time, the haemoglobin level will decline as the blood is diluted by the influx of extravascular fluid into the vascular space and by fluid administered during resuscitation. The haemoglobin level should initially be monitored every eight to twelve hours, depending upon the severity of the bleed.

Acute bleeding does not alter the mean corpuscular volume (MCV). If the MCV is low, it may suggest iron deficiency, which could be caused by chronic bleeding.

Because blood is absorbed as it passes through the small bowel and patients may have decreased renal perfusion, patients with acute upper GI bleeding typically have an elevated blood urea nitrogen to creatinine or urea-to-creatinine ratio >30:1 or >100:1, respectively, suggesting upper GI bleeding as the cause.

6. Nasogastric lavage

The use of nasogastric tube (NGT) placement in patients with suspected acute upper GI bleeding is not recommended, as studies have failed to demonstrate a benefit in clinical outcomes.

NGT lavage may be used when it is unclear if a patient has ongoing bleeding and thus might benefit from an early endoscopy.

In addition, NGT lavage can be used to remove particulate matter, fresh blood, and clots from the stomach to facilitate endoscopy. An alternative to NGT lavage in this situation is to use a prokinetic such as metoclopramide

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General management

1. Hemodynamically unstable patients

While the principles behind the management of all patients with upper gastrointestinal bleeding are similar, there are some special considerations when it comes to patients presenting with hemodynamic instability.

2. Intravenous access

Adequate peripheral access should be attained with either two 18 gauge or larger intravenous catheters and/or a large-bore, single-lumen central cordis.

3. Fluid resuscitation

Fluid resuscitation should begin immediately using crystalline fluids and should not be delayed pending the transfer of the patient to an intensive care unit. It is particularly important to ensure that these patients are adequately resuscitated before undergoing upper endoscopy.

4. Transfusion

1. For patients with active/brisk bleeding and hypovolemia, transfusion should be guided by hemodynamic parameters (eg, pulse and blood pressure), the pace of the bleeding, estimated blood loss, and the ability to stop the bleeding, rather than by serial haemoglobin measurements. If the initial hemoglobin level is low (<7 g/dL) transfusions should be initiated.
2. Patients without active bleeding who become hemodynamically stable with fluid resuscitation are managed like other patients who are hemodynamically stable.
3. For most stable patients, a restrictive transfusion strategy is appropriate (transfuse if haemoglobin is <7g/dL [<70 g/L] rather than at higher haemoglobin.
4. For most patients, the goal is to maintain the hemoglobin at a level ≥7 g/dL (70 g/L), rather than at a higher level. However, for patients at increased risk of adverse events in the setting of significant anaemia, such as those with coronary artery disease or those with evidence of ongoing active bleeding, our goal is to maintain the haemoglobin at a level of ≥8 - 9 g/dL.
5. Patients assigned to a restrictive transfusion strategy had lower all-cause mortality than those assigned to a liberal transfusion strategy (absolute risk reduction [ARR] 2.2 per cent, relative risk [RR] 0.65, 95% CI 0.44-0.97) and rebleeding (ARR 4.4 per cent, RR 0.58, 95% CI 0.40-0.84).
6. Avoiding over-transfusion is especially important in variceal bleed where chances of precipitating a rebleed are higher with a liberal transfusion strategy.

5. Triage

All patients with hemodynamic instability or active bleeding (manifested by hematemesis, bright red blood per nasogastric tube, or hematochezia) should be admitted to an intensive care unit for resuscitation close observation and continuous telemetry.

Other patients can be admitted to a regular medical ward. Outpatient management may be appropriate for some low-risk patients. Determining the appropriate site of care for a patient can be facilitated using risk stratification scores, such as the Glasgow-Blatchford score. Use of these scores is recommended in the International Consensus Group guideline.

6. General support

Patients should receive supplemental oxygen by nasal cannula and should keep NPO.

Elective endotracheal intubation in patients with ongoing hematemesis or altered respiratory or mental status may facilitate endoscopy and decrease the risk of aspiration.

However, among patients who are critically ill, elective endotracheal intubation has been associated with worse outcomes. In particular, patients who were intubated are more likely to be diagnosed with pneumonia within 48 hours (14.0 versus 2.0 per cent).

7. Thrombocytopenia

Patients with critical or life-threatening bleeding and a low platelet count (<50,000/microL) should be transfused with platelets. Limited data suggest that proceeding with upper endoscopy in patients with thrombocytopenia is generally safe, though whether there is a lower limit below which endoscopy should be delayed is unclear.

8. Managing anticoagulants, antiplatelet agents, and coagulopathies

Anticoagulants and antiplatelet agents

1. The approach to the management of anticoagulants and antiplatelet agents depends on the medications being used and their indications, how severe the bleeding is, and how quickly reversal of anticoagulation is needed.
2. For most patients, endoscopy should not be delayed because of anticoagulant or antiplatelet agent use. Provided the patient is hemodynamically stable, urgent endoscopy can usually proceed simultaneously with the management of antithrombotic medications.
3. However, for patients undergoing upper endoscopy, we wait until the INR is <2.5 to perform the endoscopy, if possible. This approach is based on data that suggest endoscopy is safe and endoscopic therapy effective in patients who are mild to moderately anticoagulated.
4. When possible, anticoagulants and antiplatelet agents should be held in patients with acute upper GI bleeding.
5. In patients with severe, ongoing bleeding who are taking an anticoagulant, administration of a reversal agent or intravenous prothrombin complex concentrate may be indicated.
6. However, the thrombotic risk of reversing anticoagulation should be weighed against the risk of continued bleeding without reversal, and thus the decision to discontinue medications or administer reversal agents needs to be individualised.
7. For antiplatelet agents, the decision to discontinue should be taken in consultation with a cardiologist if there is a history of coronary intervention within one year preceding the presentation.
8. When to resume these medications once hemostasis has been achieved will depend on the patient's risks for thrombosis and recurrent bleeding.

Coagulopathies related to cirrhosis

The management of coagulopathies in patients with cirrhosis is particularly complicated. In patients with cirrhosis, the INR is not an accurate measure of coagulation because it only reflects changes in procoagulant factors, and both procoagulant and anticoagulant factors are reduced.

Hence, the correction of coagulation parameters should be based on the global assessment of coagulation function such as thromboelastography.

Medications

Acid suppression

1. Patients admitted to the hospital with acute upper GI bleeding are typically treated with a proton pump inhibitor (PPI). The optimal approach to PPI administration before endoscopy is unclear.
2. Options include giving an IV PPI every 12 hours or starting a continuous infusion. Our approach is to give a high-dose bolus (eg, pantoprazole 80 mg) followed by continuous infusion to patients with signs of active bleeding (eg, hematemesis, hemodynamic instability).
3. Endoscopy should be performed on patients with suspected ongoing active bleeding after resuscitation within 12 hours. Subsequent dosing will then depend on the endoscopic findings.
4. PPI therapy also decreases the length of hospital stay, rebleeding rate, and need for blood transfusion in patients with high-risk ulcers treated with endotherapy. PPIs may also promote hemostasis in patients with lesions other than ulcers. This likely occurs because the neutralisation of gastric acid leads to the stabilisation of blood clots.

Vasoactive medications

1. Somatostatin, its analogue octreotide, and terlipressin are used in the treatment of variceal bleeding and may also reduce the risk of bleeding due to nonvariceal causes.
2. In patients with suspected variceal bleeding, octreotide is given as an intravenous bolus of 50 mcg, followed by a continuous infusion at a rate of 50 mcg per hour.
3. Octreotide is not recommended for routine use in patients with acute nonvariceal upper GI bleeding, but it can be used as adjunctive therapy in some cases.
4. Its role is generally limited to settings in which endoscopy is unavailable or as a means to help stabilise patients before definitive therapy can be performed.

Antibiotics for patients with cirrhosis

Bacterial infections are present in up to 20 per cent of patients with cirrhosis who are hospitalised with gastrointestinal bleeding; up to an additional 50 per cent develop an infection while hospitalised. Such patients have increased mortality.

4.  Ineffective treatments

Tranexamic acid is an antifibrinolytic agent that has been studied in patients with upper GI bleeding and does not appear to be beneficial.

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Diagnostic studies

1. Upper endoscopy

1. Upper endoscopy is the diagnostic modality of choice for acute upper GI bleeding. Additionally, endotherapy can be performed simultaneously.
2. After adequate resuscitation, upper GI endoscopy should be performed within 24 hours for most patients with upper GI bleeding, but for patients with suspected variceal bleeding, it should be performed within 12 hours of presentation.
3. The timing of endoscopy in patients with ongoing hemodynamic instability despite optimum resuscitative measures remains controversial.
4. However, it is prudent to perform endoscopy in these situations earlier than 12 hours post-presentation.
5. The presence of active bleeding during the index endoscopy is a sign of poor outcome in terms of achieving primary hemostasis and early rebleeding. However, these patients then can be assessed quickly for rescue therapies.

2. Risks of endoscopy

Risks of upper endoscopy include pulmonary aspiration, adverse reactions to medications used to achieve conscious sedation, GI perforation, and increasing bleeding while attempting therapeutic intervention.

While patients need to be hemodynamically stable before undergoing endoscopy, data suggest that patients do not need to have a normal hematocrit to safely undergo endoscopy. In addition, endoscopy appears to be safe in patients who are mild to moderately anticoagulated.

The risks versus benefits of upper endoscopy should be considered in high-risk patients, such as those who have had a recent myocardial infarction. In one study, for example, 200 patients who underwent endoscopy within 30 days after myocardial infarction (MI) were compared with 200 controls matched for age, sex, and endoscopic indication.

Complications (including fatal ventricular tachycardia, near respiratory arrest, and mild hypotension) occurred more often in patients who had a recent MI (8 versus 2 per cent).

Complications occurred more often (21 versus 2 per cent) in patients who were very ill (Apache II score >16 or hypotension before endoscopy).

However, such patients are at increased risk for complications even without endoscopy and may be particularly vulnerable to complications from continued bleeding without endoscopy.

3. Other diagnostic tests

Other diagnostic tests for acute upper GI bleeding include:

• CT angiography and digital subtraction angiography can detect active bleeding
• Deep small bowel enteroscopy, and rarely, intraoperative enteroscopy

There is also interest in using wireless capsule endoscopy for patients who have presented to the emergency department with suspected upper GI bleeding.

An oesophagal capsule (which has a recording time of 20 minutes) can be given in the emergency department and reviewed immediately for evidence of bleeding. Confirming the presence of blood in the stomach or duodenum may aid with patient triage and identify patients more likely to benefit from early endoscopy.

Small bowel capsule endoscopy has also been employed to help localise bleeding in patients with acute gastrointestinal bleeding without hematemesis.

A colonoscopy is generally required for patients with hematochezia and a negative upper endoscopy unless an alternative source for the bleeding has been identified.

In addition, patients with melena and a negative upper endoscopy frequently undergo colonoscopy to rule out a colonic source for the bleeding, as right-sided lesions may present with melena.

Following a non-diagnostic upper endoscopy, a suspected bleeding source was identified in 5 per cent of patients on colonoscopy.

Despite the relatively low yield in patients with melena, we routinely perform a colonoscopy in patients with melena and a negative upper endoscopy, as well as in patients with hematochezia.

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Risk stratification

Endoscopic, clinical, and laboratory features may be useful for risk stratification of patients who present with acute upper GI bleeding, and the use of risk stratification tools is recommended by the International Consensus Group. Factors associated with rebleeding identified in a meta-analysis included:

• Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart rate greater than 100 beats per minute)
• Hemoglobin less than 10 g/L
• Active bleeding at the time of endoscopy
• Large ulcer size (greater than 1 to 3 cm in various studies)
• Ulcer location (posterior duodenal bulb or high lesser gastric curvature)

An increase in the blood urea nitrogen (BUN) level at 24 hours compared with baseline may be another predictor of poor outcomes

Risk scores

1. Two commonly cited scoring systems are the Rockall score and the Blatchford score.
2. The International Consensus Group suggests using a Glasgow Blatchford score (GBS) of ≤1 to identify patients who are at very low risk for rebleeding or mortality and who can be considered for outpatient management.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Parag Dashatwar is a DNB gastroenterologist, who leads the department of medical gastroenterology at Olive Hospital, Hyderabad.