GIT bleeding.

Overview

This is usually due to peptic ulcer disease or oesophageal varices, and as such is predominantly a surgical priority. Sometimes there is confusion about whether the patient has haemoptysis or haematemesis.

Feature	Lung	GIT
History of chronic cough	Common	Rare
Bright blood	Common	Usually ‘darker’
Melaena	Rare, not unheard of	Often
Clubbed	Sometimes	Seldom (Ca stomach)
Lung signs	Very common	Seldom unless aspiration
CXR	Infiltrate/cavity/destruction	Usually normal

Upper GIT bleeding remains a serious condition, with reported overall mortality of the order of 10%,¹ however this is age-dependent with mortality rates of 3.3% for those less than 31 years and 14.4% for those older than 71 years.² A patient with hypotension and tachycardia has a higher mortality than one without these signs – a volume loss of 15% may be tolerated without marked tachycardia or hypotension, so when these are present vigorous resuscitation with 3 or 4 litres of saline and blood may be appropriate. In any suspected GIT bleed:

• Insert a large bore (preferably 16G) cannula and a saline infusion while taking the history and checking vital signs. A second line may be a good idea if the patient is clearly in shock.
• Take blood for cross match, FBC, INR/PTT and a U&E.
• Fluids – crystalloid such as saline, usually need at least three litres – but titrate against BP and pulse rate.
• Blood – if hypotensive and anaemic, transfuse.
• Organise oesophagoscopy/gastroscopy as soon as feasible. More than two thirds of bleeds are due to either gastric or duodenal ulcers or gastric erosions; oesophageal pathology accounts for most of the rest (varices, mucosal tears, oesophagitis).

Risks and benefits of gastroscopy in upper GIT bleeding:

In one review,³ sensitivity was over 90%, and specificity 95% (LR+ 18.0, LR- 0.11.) Major complications were perforation, aspiration and haemorrhage, which together occurred in 0.5% of all scopes. The mortality rate was 0.1%. (It is also worth remembering that barium studies perform far less well than scope – sensitivity 60%, specificity 90% (same source as above) yielding LR+ of 6.0 and LR- of 0.44).

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Perspective – nasogastric aspirate as predictor of mortality

A review⁴ found that if the aspirate was coffee grounds with normal or melaena stool, mortality was 8.2%, versus 12.3% for a bloody aspirate with melaena stool.  However coffee grounds with red blood PR was associated with 19.1% mortality, and a bloody nasogastric aspirate with bloody stool with mortality of 28.7%.

The clinical risk factors for high mortality in GIT bleeding are well known, and include shock on admission (pulse >100, SBP <100), comorbidity (liver or renal failure or malignancy), rebleeding, being very elderly, and having certain endoscopic features such as an actively bleeding vessel in an ulcer, a visible blood vessel, even if not bleeding, and varices with haemorrhagic spots.⁵

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Medication in upper GIT bleeding.

There is little doubt that the definitive treatment of upper GIT bleeding is interventive – either with endoscopic techniques or with surgery, and every effort should be made to get patients to facilities where such techniques are available.

The vogue for the use of acid reducing agents should be viewed with some caution. Cimetidine and ranitidine, even intravenously, are of little benefit. The evidence on the proton pump inhibitors given prior to gastroscopy did not show benefit on mortality, re-bleeding or need for surgery. ⁶

After endoscopy, benefit is very unlikely in patients with bleeding varices; however there is clearly benefit in those with bleeding peptic ulcers; oral therapy is probably as successful as high dose IV therapy⁷

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1. Fallah MA, Prakash C, Edmundowicz S. Acute gastrointestinal bleeding. Med Clin North Am. 2000;84:1183-208 ↩

2. Peter DJ, Dougherty JM. Evaluation of the patient with gastrointestinal bleeding: an evidence based approach. Emerg Med Clin North Am. 1999;17:239-61 ↩

3. Black ER, Bordley DR, Tape TG, et al. Diagnostic strategies for common medical problems. Am Coll Physicians – American Society of Internal Medicine. 1999. p120-1. ↩

4. Kupfer Y, Cappell MS, Tessler S. Acute gastrointestinal bleeding in the intensive care unit. The intensivist’s perspective. Gastroenterol Clin North Am. 2000;29:275-307 ↩

5. Dallal HJ, Palmer KR.  ABC of the upper gastrointestinal tract.  Upper gastrointestinal haemorrhage. BMJ. 2001;323:1115-7 ↩

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:CD005415 ↩

7. Jian Z, Li H, Race NS, Ma T, et al. Is the era of intravenous proton pump inhibitors coming to an end in patients with bleeding peptic ulcers? Meta-analysis of the published literature. Br J Clin Pharmacol. 2016 Sep;82(3):880-9. doi: 10.1111/bcp.12866. Epub 2016 Jun 12. PMID: 26679691; PMCID: PMC5338121. ↩

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