Upper Gastrointestinal Bleeding (UGIB Bleeding) Rockall …

Acute upper gastrointestinal bleeding (UGIB) is a gastroenterological emergency with a mortality of 6%-13%.[1] Despite changes in management, mortality has not significantly improved over a period of 50 years.[2] Bleeding from the upper gastrointestinal tract (GIT) is about four times as common as bleeding from the lower GIT. It is important to identify patients with a low probability of re-bleeding from patients with a high probability of re-bleeding. The size of the bleeding vessel is important in prognosis. Visible vessels are usually between 0.3 mm and 1.8 mm. Large bleeding vessels cause faster blood loss. Generally, larger vessels are found deeper in the submucosa and serosa and more specifically high in the lesser curve of the stomach and postero-inferiorly in the duodenal bulb.

Endoscopy does not reveal a cause in approximately 20% of patients presenting with apparent acute UGIB. The most common causes are peptic ulcer and oesophago-gastric varices.[3]

Rare causes include:

The incidence of acute UGIB in the UK ranges between 84-172 per 100,000 per year, causing 50-70,000 hospital admissions per year.[2]

An ageing population with associated conditions and a worse prognosis has helped maintain constant mortality figures despite advances in treatment. Mortality is about 7% in patients admitted because of bleeding but some three times higher amongst those developing UGIB whilst in hospital.[3] Peptic ulcer disease is the most common cause of UGIB. Risk factors for peptic ulcer disease are:

Although duodenal ulcers are more common than gastric ulcers, both contribute nearly equally to the incidence of UGIB. After an initial bleed the risk factors for re-bleeding, with associated higher mortality, are:

Bleeding severity can be assessed by:[4]

Initial assessment may provide an indication of the cause of UGIB:

The main aim of examination is to assess blood loss and look for signs of shock. A secondary aim is to look for signs of underlying disease and significant comorbid conditions - for example:

Endoscopy is the primary diagnostic investigation in patients with acute UGIB:[2]

Consider for admission and early endoscopy (and calculation of full Rockall score) if:

Other significant comorbidity (especially cardiac disease, malignancy) should also lower the threshold for admission.

Shocked patients should receive prompt volume replacement. It has been demonstrated that early and aggressive resuscitation reduces mortality in UGIB.[5]

Proton pump inhibitors (PPIs) should not be used prior to diagnosis by endoscopy in patients presenting with acute UGIB.[3]

Recommendations emphasise early risk stratification, using validated prognostic scales, and early endoscopy (within 24 hours).[8] The following formal risk assessment scores are recommended by the National Institute for Health and Care Excellence (NICE) for all patients with acute UGIB:[2]

The Blatchford risk assessment is designed to be used pre-endoscopy (see the full NICE Guideline for details).[2]Scores are added using the level of urea, haemoglobin, systolic blood pressure, pulse rate, presentation with melaena, presentation with syncope, hepatic disease and cardiac failure. A score of 0 is the cut-off with any patient scoring >0 being at risk of requiring an intervention.

The Scottish Intercollegiate Guidelines Network (SIGN) guideline on the management of acute upper and lower gastrointestinal bleeding recommends that an initial (pre-endoscopic) Rockall score be calculated for all patients presenting with acute UGIB. In patients with an initial Rockall score >0, endoscopy is recommended for a full assessment of bleeding risk.[3]

Adapted with permission from BMJ Publishing Group Limited. Original tables in Rockall TA, Logan RF, Devlin HB, et al; Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996 Mar; 38(3):316-21. 1996 BMJ Publishing Group Limited.

Endoscopy is now the method of choice for controlling active peptic-ulcer related UGIB.[10]Endoscopic therapy should only be delivered to actively bleeding lesions, non-bleeding visible vessels and, when technically possible, to ulcers with an adherent blood clot. Black or red spots or a clean ulcer base with oozing do not merit endoscopic intervention since these lesions have an excellent prognosis without intervention.[3]

Adrenaline (epinephrine) should not be used as monotherapy for the endoscopic treatment of non-variceal UGIB. For the endoscopic treatment of non-variceal UGIB, one of the following should be used:

Acid-suppression drugs (PPIs or H2-receptor antagonists) should not be offered before endoscopy to patients with suspected non-variceal UGIB. PPIs should be offered to patients with non-variceal UGIB and stigmata of recent haemorrhage shown at endoscopy.

Surgical intervention is required when endoscopic techniques fail or are contra-indicated. Clinical judgement is required and consideration given to local expertise.

Helicobacter pylori eradication - see separate Helicobacter Pylori article:

The complications of UGIB are self-evident. Other complications can arise from treatments administered - for example:

Elderly patients and people with chronic medical conditions withstand acute UGIB less well and have a higher risk of death.[2] Mortality is about 7% in patients admitted with an UGIB. It is as high as 26% in patients who develop bleeding whilst in hospital having been admitted for another cause.[3] A score of less than 3 using the Rockall Score system above is associated with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.[9]

Factors which affect the risk of death include:

Mortality is reported to be lower in specialist units, possibly because of adherence to protocols rather than because of technical advances. The prognosis in liver disease relates significantly to the severity of the liver disease rather than to the magnitude of the haemorrhage.

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Upper Gastrointestinal Bleeding (UGIB Bleeding) Rockall ...