Haematemesis / Melaena – Evening Medical Update Series at Royal College of Physicians Edinburgh 24th April

It’s 9pm in ED and a patient presents with haematemesis – Dr Sarah Hearnshaw Consultant Gastroenterologist, Royal Victoria Infirmary, Newcastle upon Tyne

The scope of this talk was:

  • Risk Assessment
  • transfusion strategies
  • Drug therapy
  • Timing of endoscopy

AUGIB (Acute Upper GI Bleed) in UK – mortality hasn’t really shifted in last 20 years and the percentage caused by varices has increased slightly.

The role of the risk assessment is to:

  • identify who can go home
  • stratify who needs urgent attention
  • but does not replace “end of bed” test
  • makes you do all the important tests
  • Glasgow Blatchford Score most common – the most useful according to Dr Hearnshaw: blood urea, haemoglobin, SBP and other markers give you points.

If score is 0 or 1, can go home as do not require early “scope or admission”.

Which fluids when?

Resuscitate these patients and don’t be worried about “over-resus-ing”. Plenty of crystalloids fluids.

Furthermore, excessive transfusion can make things worse – re-bleeding. Restricted transfusion patients do much better in the general literature. This means only transfusing patients with cardiac disease or severe bleeding. Dr Hearnshaw’s point of view is that individualised care is key.

NICE guidelines (shortened)

1.2 Resuscitation and initial management

1.2.1 Transfuse patients with massive bleeding with blood, platelets and clotting factors in line with local protocols for managing massive bleeding.

1.2.2 Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion.

1.2.4 Offer platelet transfusion to patients who are actively bleeding and have a platelet count of less than 50 x 109/litre.

Whilst NICE longer recommends specific numbers to aim for, I think it is useful for decision to have a number in mind in the context of the patient in front of you – NICE 2015 said: “The recommended Hb transfusion threshold is 70 g/L with a post-transfusion Hb target of 70-90 g/L in patients without acute coronary syndrome”, as opposed to the old thresholds of 90 g/L.

In suspected variceal bleeding, antibiotics and terlipressin (leads to splanchnic constriction) improve survival.

When to scope?

NICE says that everyone admitted should have an endoscopy within 24 hours – or “after resuscitation” if unstable. Units with >330 cases/year should have a daily scope list. The scope should be within 12 hours if ongoing CVS instability.

Peptic Ulcer Disease – Dr Sian Gilchrist, Consultant Gastroenterologist, Victoria Hospital, Kirkcaldy

A few interesting points here. RE anti-platelet agents, NICE recommends not stopping aspirin in those patients in whom haemostasis has been achieved. Dr Gilchrist gave the anecdote of patients who have their NSTEMI day 5 post-GI bleed, because GI bleed is an inflammatory therefore pro-thrombotic state.

Managing variceal bleeding – Dr Steven Masson, Consultant Gastroenterologist, Freeman Hospital, Newcastle upon Tyne

Prevention and treatment of variceal haemorrhage in 2017 – Felix Brunner, Annalisa Berzigotti, Jaime Bosch 2017 abstract sums this up:

Variceal haemorrhage is a major complication of portal hypertension that still causes high mortality in patients with cirrhosis. Improved knowledge of the pathophysiology of portal hypertension has recently led to a more comprehensive approach to prevent all the complications of this condition. Thus, optimal treatment of portal hypertension requires a strategy that takes into account the clinical stage of the disease and all the major variables that affect the risk of progression to the next stage and death.

In patients with compensated liver disease, the correction of factors influencing the progression of fibrosis, in particular aetiologic factors, is now feasible in many cases and should be achieved to prevent the development or progression of gastroesophageal varices and hepatic decompensation.

Once gastroesophageal varices have developed, non‐selective beta‐blockers remain the cornerstone of therapy. Carvedilol provides a greater decrease in portal pressure and is currently indicated as a first‐choice therapy for primary prophylaxis.

The treatment of acute variceal haemorrhage includes a combination of vasoactive drugs, antibiotics and endoscopic variceal band ligation.

In high‐risk patients, the early use of transjugular intrahepatic portosystemic shunt (TIPS) lowers the risk of re‐bleeding and improves survival.

Transjugular intrahepatic portosystemic shunt is the choice for uncontrolled variceal bleeding; a self‐expandable metal stent or balloon tamponade can be used as a bridging measure.

The combination of non‐selective beta‐blockers and endoscopic variceal band ligation reduces the risk of recurrent variceal bleeding and improves survival. In these cases, statins seem to further improve survival – not entirely explained yet.

Transjugular intrahepatic portosystemic shunt is indicated in patients who rebleed during secondary prophylaxis.

“At diagnosis, up to half of the patients with compensated cirrhosis have developed Gastroeosophageal varices (GEV).”

Pathophysiology:

BSG UK Guidelines for the Management of Variceal Haemorrhage in Cirrhotic Patients:

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