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Home | Articles | Gastrointestinal | Acute Upper GI Bleeding (AUGIB)

Acute Upper GI Bleeding (AUGIB)

Last updated 24th January 2022

2018 AUGIB Guideline

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Blatchford Score

Score Value
Blood urea (mmol/L)
6.5-7.9
2
8.0-9.9
3
10.0-25.0
4
>25.0
6
Haemoglobin for men (g/L)
120-129
1
100-119
3
<100
6
Haemoglobin for women (g/L)
100-119
1
<100
6
Systolic blood pressure (mmHg)
100-109
1
90-99
2
<90
3
Other markers
Pulse ≥100/min
1
Presentation with melaena
1
Presentation with syncope
2
Hepatic disease*
2
Cardiac failure‡
2
*Known history, or clinical and laboratory evidence of chronic or acute liver disease. ‡Known history, or clinical and echocardiographic evidence of cardiac failure

Recognition

  1. Haematemesis and/or melaena, but note also syncope, anaemia and coffee grounds.
  2. Coffee grounds may be 2y to other problem eg DKA, intestinal obstruction
  3. Ask about drugs that might make them bleed eg antiplatelet, anticoagulant
  4. Consider oesophageal tear – repeated retching before the bleed.
  5. Look for signs chronic liver disease and portal HT
  6. Telangiectasia on lips suggests HHT and history aortic graft raises possibility aorto-duodenal fistula – both rare
  7. Always do rectal exam to look for melaena.
  8. Hb <100g/l on admission suggests significant bleed
  9. Pale, clammy and confused with tachycardia and hypotension suggests severe bleed
  10. Clotting screen if alcoholic, on warfarin or > 4 units blood given in 12 hours.
  11. G&S only for minor bleed eg oesophageal tear or young adult male with small alcohol related haematemesis
  12. Cross match minimum of 2 units for the rest

Resuscitate (the bad bleeders)

  1. Use ABCDE approach if looks unwell
  2. Admit or transfer critical care
  3. Ensure two grey venflons, nil by mouth, high flow oxygen (> 6l/min), catheterise and give morphine if agitated.
  4. Give IV crystalloid
  5. Transfuse if active bleeding or unstable after initial resuscitation. Better outcomes if restrict transfusion to Hb <70g/l unless patient has massive haemorrhage or cardiac disease

Risk Assessment

  1. Calculate Glasgow Blatchford Score
  2. If no value applies for a particular marker, score 0.
  3. A total score can range from 0-23.
  4. A score of 1 is the clinical cut off, above which patients are considered to be at risk of needing an intervention
  5. Consider for discharge with outpatient follow up if age <60 and Blatchford Score 0 or 1
  6. Exclusion criteria for Blatchford Score include social circumstances requiring admission; other medical conditions requiring admission; on anticoagulants; other clinical concern (reason for choosing inpatient management should be documented in the notes).

Rx

  1. Aim for Hb 70-90g/l (80-100g/l at discharge) in stable patients.
  2. In patients without cardiac comorbidity offer transfusion when Hb <70g/l. If cardiac comorbidity/old/frail offer transfusion when Hb <80g/l
  3. Patients with coagulopathy should receive urgent correction where possible though this may not always be safe if high risk of thrombosis eg metallic heart valve or recent diagnosis PE
  4. Safe to continue aspirin in high risk cardiac patients but suspend all other antithrombotics
  5. Discuss with haematologist who is likely to advise platelet transfusion if platelets <50,000, FFP if INR >1.5 and Prothrombin complex concentrate (Beriplex) 30 units/kg IV with vitamin K 5mg IV if on warfarin with INR >1.5
  6. If suspected variceal bleed give terlipressin 2mg qds IV and empirical antibiotics eg Co-amoxiclav 1.2g tds IV OR Ciprofloxacin 400m bd IV. Without antibiotics 50% patients with variceal bleed will develop a significant infection
  7. Do not prescribe tranexamic acid routinely unless end of life care
  8. There is conflicting evidence whether to give IV PPI before endoscopy. NICE and BSG do not recommend routine PPI administration as may mask targets for therapy. If endoscopy likely to be delayed could consider lansoprazole fastab

Refer

  1. Unstable patients should be managed on critical care
  2. Patients with ongoing haemodynamic instability or with GBS >12 should have 24/7 access to urgent endoscopy within 2-12 hours
  3. All other patients with AUGIB should have early endoscopy within 24 hours unless endoscopy not appropriate eg minor oesophageal tear, end of life care or GBS 0 or 1 in which case endoscopy can be arranged as outpatient
  4. Patients with bright red rectal bleeding (BRRB) should be managed on a surgical ward unless AUGIB suspected.
  5. Patients with BRRB and haemodynamic instability should also be referred for urgent endoscopy. If this is normal urgent sigmoidoscopy ± CT angiogram may help establish a bleeding source.
  6. Early colonoscopy should be encouraged if colonic bleed suspected
  7. Click here for Inpatient Upper GI Bleed Referral Form [pdf]

Review

  1. Review endoscopy report
  2. Patients with peptic ulcers considered at high risk of rebleeding should be started on omeprazole 40mg bd IV for 72 hrs or a high dose oral equivalent in selected patients.
  3. Consider Helicobacter eradication if appropriate.  See Handbook page on H Pylori Eradication
  4. Safe to restart antithrombotic therapy after successful endoscopic control of GI bleeding.  Current cardiac and GI society consensus statements recommend restarting antiplatelet therapy as soon as haemostasis achieved
  5. PPI should be coprescibed if bleeding is aspirin or clopidogrel related

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