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Upper Gastrointestinal Bleeding Management

Rockall Score (predicts rebleeding and death) Forrest classification
Cause of bleeding: Relative frequency
0 1 2 3

Age >60 60­79 >80

(Endoscopic score)
Peptic ulcer. 44 Shock Not Tachycardia Hypotension
1A ­ spurting
Oesophagitis. shocked Active bleeding during endoscopy 90 % recurrence
28 CHF/ IHD/ Renal failure/ liver failure/ 1B ­ oozing
Comorbidity None
Gastritis/ erosions. 26 any major disseminated malignancy 2A ­ visible vessel Visible vessel 50 % recurrence
Erosive duodenitis. 15 Diagnosis 2B ­ clots
Varices. 2C ­ Black spot at base An adherent clot 25 to 30 % recurrence
13 Black or red spot at base negligeable rebleed rate
Portal hypertensive gastropathy. 7 Major stigmata of recent None or dark Blood in upper GI tract/ 3 ­ clean
haemorrhage spot only adherent clot, visible or
Malignancy. 5 spurting vessel
Mallory­ Weiss Tear. 5
Vascular Malformation. 3
If the initial (pre­endoscopic) score > 0 then
significant mortality (score 1: 2.4%; score 2: 5.6%)

Indications for Endoscopy Within 24 hours:

Active bleeding.
­Haematemesis ongoing.
­Fresh melaena ongoing.
­Hypotension or sinus tachycardia not responsive to resuscitation.
­Persistently low Hb despite transfusion.

Resuscitation Endoscopy Acid Suppression Repeat Endoscopy

Repeat if difficult endoscopy or rebleed likely to be life
threatening.
Repeat OGD can reduce rebleeding rates but doesnt
Indications For Endoscopic Therapy: Acid Suppression confer survival benefit.
­Active bleeding. PPI reduces risk of rebleeding .
­Visible vessel. iv PPI Before endoscopy reduces
­Adherent clot if technically possible ­snare adherent clots if bleeding signs but no effect on mortality. Rebleed
cant be removed with suctioning/ irrigation. H2 No good really for ulcers. Gastric ulcers along the lesser curvature and duodenal
Clas s I Clas s II Clas s III Clas s IV
Oral PPI for bleeding. bulbar ulcers in the posterior wall appeared to be at
Blood los s
volume (ml)
<750 750­1500 1500­2000 >2000 Endoscopic Therapy High dose of oral omeprazole (40 mg PO greater risk for severe bleeding or rebleeding compared
The use of combination therapy (adrenaline + one other BID) was associated with a decreased risk with ulcers in other locations because of their proximity to
Blood los s (%
of circulating 0­15 15­30 30­40 >40
therapy) reduces the mortality from 5.6% to 2.6%. of recurrent bleeding in patients who had large underlying arteries (left gastric and posterior
blood)

Sys tolic blood No change Normal Reduced Very reduced/ Clips are more effective than epinephrine alone, but not ulcers with a visible vessel or adherent gastroduodenal arteries, respectively).Options:
pres s ure unrecordable
different than other therapies. clots who did not undergo endoscopic
Dias tolic blood No change Rais ed Reduced Very reduced/ The efficacy of endoscopic therapies for clots was uncertain. therapy.
pres s ure unrecordable
Puls e (beats Slight 100­200 120 (thready) <120 (very
Thermal coagulation has the same efficacy as adrenaline if
per minute) tachycardia thready) used alone. SOMATOSTATIN AND OCTREOTIDE
Res piratory rate Normal Normal Rais ed Rais ed
(>20/min) (>20/min) Thermal coagulation should be used until area is blackened Repeat Angiogra ­ Sur ­
M ental s tate Alert, thirs ty Anxious or Anxious , Drows y,
and cavitated. Somatostatin or octreotide can be used as
aggres s ive aggres s ive or confus ed or OGD phy gery
drows y uncons cious
If Injection therapy with adrenaline is given alone, the adjunctive therapy before endoscopy, or
Adapted from Bas kett, PJ F. ABC of major trauma. M anagement of Hypovolaemic Shock.BM J 1990;
300: 1453­1457
rebleeding rate is high (18 %). when endoscopy is unsuccessful, contrain ­
dicated, or unavailable due to its splanchnic Surgery and transcatheter
Use 13ml 1:10,000 adrenaline.
vasoconstrictive effects arteriography/intervention (TAI) are equally
Mechanical Therapy is more effective than adrenaline alone
Typical dose of somatostatin is 250 mcg effective following failed therapeutic
Argon plasma coagulation ­can be effective although it
then hourly for 3­7d while a typical dose of endoscopy, but TAI should be considered
doesnt involve tamponade.
octreotide was 50 to 100mcg then particularly in patients at high risk for surgery.
25mcg/hr for up to 3 days. TAI is less likely to be successful in patients with
impaired coagulation.
TAI is the best technique for treatment of
bleeding into the biliary tree or pancreatic duct.

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