A Guideline for the Management of Acute Upper Classification: Clinical Guideline Lead Author: Dr Abby Conlin, Clinical Director in Endoscopy Authors Division: Salford Health Care (Acute Medicine 2) Unique ID: 250TD(C)54 Issue number: 3 Expiry Date: June 2017 Contents Section Page Intro Who should read this document 2 Key practice points 2 Background/ Scope/ Definitions 3 What is new in this version 4 Policy/Procedure/Guideline 4-9 Flow Diagram Management of Non-variceal bleeding 10 Flow Diagram Management of Variceal Bleeding 11 Standards 12 References and Supporting Documents 12 Roles and Responsibilities 12 Document control information (Published as separate document) 13-16 Document Control Policy Implementation Plan Monitoring and Review Endorsement Equality analysis Page 1 of 14
Who should read this document? All clinical staff involved in the management of patients presenting with acute upper GI bleeding. Specifically this includes doctors and nurses working in the Emergency Department, EAU, inpatient wards, critical care unit and theatres. Key Practice Points Resuscitate patients appropriately with care not to over transfuse. Risk assess every patient presenting with acute UGIB using Blatchford Score (GBS). Consider discharge in patients with acute UGIB and a GBS of 0 with planned early outpatient endoscopy. Acid-suppression drugs should not be offered to patients before endoscopy. Terlipressin and antibiotics should be given to all patients with suspected variceal acute UGIB (unless contraindicated). Unstable patients with GBS >5 should be offered endoscopy immediately after resuscitation. A surgical assessment forms a routine part of management planning in unstable patients with suspected non-variceal acute UGIB. Anaesthetic assessment is required in all patients where emergency endoscopy in theatres is planned. Patients who re-bleed after endoscopic treatment should be referred urgently for surgery. Interventional radiology is not immediately available at Salford Royal Hospital (see section 4.6.8). Page 2 of 14
Background/ Scope/ Definitions 1.0 Introduction and Objective: 1.1 Acute upper gastrointestinal bleeding (UGIB) is a common medical emergency with a 10% hospital mortality rate. The most common causes are peptic ulcer (non-variceal bleeding) and oesophago-gastric varices (variceal bleeding). Endoscopy is the primary diagnostic investigation and also allows treatments to be delivered that can stop bleeding or prevent re-bleeding. 1.2 The purpose of this document is to provide a framework for the management of acute UGIB and to ensure correct processes are followed. 1.3 This policy is applicable to all staff involved in managing patients with acute UGIB. 2.0 The Protocol Covers: 2.1 Patients with acute variceal and non-variceal upper gastrointestinal bleeding 2.2 Assessment of risk (including scoring system) 2.3 Initial patient management 2.4 Timing of endoscopy 2.4 Emergency endoscopy in theatres 3.0 The Policy Does Not Cover: 3.1 Lower gastrointestinal bleeding 3.2 Chronic gastrointestinal bleeding Page 3 of 14
What is new in this version? This version incorporates the NICE guidance on the management of acute upper gastrointestinal bleeding issued June 2012. The previous version of this policy was published in 2002. Clinical Guideline 4.1 Recognition of Acute Upper GI Bleeding 4.1.1 Patients with acute UGIB can present with the following features; -haematemesis -melaena -coffee ground vomiting -anaemia -syncope -postural hypotension -shock 4.1.2 Patients may present with anaemia, syncope, postural hypotension or shock in the absence of acute UGIB. 4.1.3 Features suggestive of acute UGIB caused by variceal bleeding include an established diagnosis of liver disease or clinical signs of undiagnosed liver disease (stigmata of chronic liver disease, serum markers of chronic liver disease). 4.1.4 Features suggestive of a non-variceal cause for acute UGIB include previous non-variceal bleeding, anticoagulant/antiplatelet/nsaid use and no evidence of chronic liver disease. 4.1.5 It is recognised that non-variceal UGIB can occur in patients with established liver disease. However, patients presenting with acute UGIB bleed with a diagnosis of (or features suggestive of) chronic liver disease should be managed as a variceal bleed. Page 4 of 14
4.2 Risk Assessment 4.2.1 All patients with suspected upper GI blood loss should have a formal risk assessment score using the Glasgow Blatchford Score (Table 1). 4.2.2 Blatchford Score (GBS) should be documented in clinical notes and on endoscopy request forms. Table 1 Glasgow Blatchford Score Presenting Risk Marker Score Blood Urea 6.5 <8.0 8.0 <10.0 10.0 <25 25 2 3 4 6 Haemoglobin (g/l) for men 120 <130 100 <120 <100 1 3 6 Haemoglobin (g/l) for women 100 <120 <100 1 6 Systolic Blood Pressure (mmhg) 100-109 90-99 <90 1 2 3 Other Markers Pulse 100/minute Presentation with melaena Presentation with syncope Chronic Liver Disease Cardiac Failure 1 1 2 2 2 Page 5 of 14
4.2.3 Patients with a Blatchford Score of 0 should be considered for discharge from hospital with early outpatient endoscopy. 4.2.4 Unstable patients with GBS >5 (high risk bleed) should be discussed with a gastroenterology registrar, associate specialist or consultant Monday to Friday 9am-5pm and the on call endoscopist at any other time. 4.2.5 UGIB occurring in patients who have been in hospital for >24 hours should be discussed with a gastroenterology registrar, associate specialist or consultant. 4.3 Resuscitation and Initial Management 4.3.1 Patients with massive bleeding should have blood, platelets and clotting factors in line with the hospital policy for massive blood loss. 4.3.2 Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as undertransfusion. In general blood transfusion should be given if Hb is less than 70 g/l (aim for target Hb of 70-90 g/l). 4.3.3 Offer platelet transfusion only to patients who are actively bleeding and have a platelet count of less than 50 x 10 9 per litre. 4.3.4 Fresh frozen plasma should be offered in the following situations: -Fibrinogen level < 1g / litre -PT (INR) or APTT of > 1.5 times normal 4.3.5 Offer prothrombin complex concentrate to patients who are taking Warfarin and actively bleeding 4.3.6 Do not offer acid-suppression drugs (proton pump inhibitors or H2- receptor antagonists) before endoscopy to patients with UGIB. 4.3.7 All patients with suspected variceal blood loss should be given terlipressin (2mg every 4 hours, or reduce to 1mg after initial dose if not tolerated or body weight under 50kg) and antibiotics (as per hospital antibiotic policy). This should be administered no later than 4 hours after variceal bleeding is suspected and continued until the outcome of the endoscopy is known. Page 6 of 14
4.3.8 All patients with cirrhotic liver disease and non-variceal blood loss should continue to receive antibiotics after endoscopy. 4.3.9 Care should be taken with the volume of fluid used to resuscitate patients with variceal bleeding or cardiovascular comorbidity as overly aggressive resuscitation will have a negative impact on outcome. 4.3.10 In patients where there is concern of Terlipressin induced cardiac ischaemia, somatostatin or its analogue can be used. Somatostatin/ octreotide causes selective splanchnic vasoconstriction and reduces portal pressure and portal blood flow. Octreotide is given as an infusion of 25-50mcg/hour. Somatostatin is given as a 250mg intravenous bolus followed by an infusion of 250mg/hour. 4.4 Timing of Endoscopy (also see table 2) 4.4.1 Unstable patients with GBS >5 (high risk bleed) should be offered endoscopy immediately after resuscitation. 4.4.2 All other patients with acute UGIB and a GBS 1 should be offered endoscopy within 24 hours. 4.4.3 Consider discharge in patients with acute UGIB and a GBS of 0 with planned early outpatient endoscopy. 4.4.4 If endoscopy is required outside 08:30am-5pm Monday to Friday and 08:30 am-12:30pm on Saturday, the endoscopic procedure will be carried out in emergency theatres by the on-call endoscopist. 4.4.5 Endoscopy is carried out for stable patients with acute upper GI bleeding in the endoscopy unit between the hours of 08:30 am-5pm Monday to Friday and 08:30am 12:30pm on Saturdays. 4.4.6 The endoscopy unit (extension 65959 or 65958) must be notified of stable patients with acute UGIB requiring endoscopy in GIU on Saturdays before 10:30am. Page 7 of 14
Table 2 Arranging Endoscopy contact information Mon-Fri 09:00-17:00 Mon-Fri 17:00-09:00 Sat 08:30-12:30 Sat 12:30-Mon 09:00 Stable Patients Send electronic referral and discuss with endoscopy Unit coordinator on ext. 65959 or 65958 Send electronic referral and discuss with endoscopy Unit coordinator on ext. 65959 or 65958 at 08:30. Medical registrar review if any concerns. Send electronic referral and notify the endoscopy unit coordinator on ext. 65959 or 65958 before 10:30. Send electronic referral and discuss with endoscopy Unit coordinator on ext. 65959 or 65958 at 08:30 Mon morning. Medical registrar review if any concerns. Unstable Patients GBS >5 Attend endoscopy unit and discuss with coordinator and endoscopist. Registrar or consultant to discuss with the endoscopist on call. Registrar or consultant to discuss with the endoscopist on call. Registrar or consultant to discuss with the endoscopist on call. 4.5 Emergency Endoscopy in Theatres (also see table 2) 4.5.1 Unstable patients with GBS >5 (high risk bleed) presenting 5pm 9am weekdays and 9am-9am weekend days should be discussed with the endoscopist on call to consider emergency endoscopy in theatres. 4.5.2 The team responsible for the overall care of the patient should liaise with the theatre coordinator to add the case to the emergency list. 4.5.3 The team responsible for the overall care of the patient should liaise with the on-call anaesthetist on 61852 to enable them to support the patient during emergency endoscopy. 4.5.4 The team responsible for the overall care of patients with suspected acute non-variceal UGIB should liaise with the surgical registrar on call to enable appropriate surgical support. 4.5.5 The team responsible for the overall care of the patient should ensure the patient has received appropriate resuscitation prior to transfer to theatre. Page 8 of 14
4.5.6 Establish a clear plan for action to be taken in the event of uncontrolled GI haemorrhage prior to transfer to theatre. 4.5.7 Establish the ward to which the patient will be discharged to following the procedure prior to transfer to theatre. 4.5.8 The team responsible for the patient must make sure that a team member is available to accompany the patient to theatre and provide a handover. In situations when this is not possible, such as dealing with another emergency, the team must ensure an adequate handover to the anaesthetist and surgical team on call. 4.6 Management of Non-variceal UGIB 4.6.1 One of the following methods should be used if endoscopic therapy is required; -mechanical method (clips) with or without adrenaline injection -thermal coagulation (heater probe) with adrenaline injection -fibrin or thrombin with adrenaline injection -Hemospray or equivalent may be used if the above modes of therapy are ineffective or cannot be applied 4.6.2 Adrenaline monotherapy should not be used. 4.6.3 If endoscopic therapy is applied, patients should receive a stat intravenous dose of Omeprazole 80mg followed by 8mg per hour intravenous infusion for 72 hours. 4.6.4 Repeat endoscopy within 24 hours should be arranged if initial endoscopic therapy was suboptimal. 4.6.5 H. pylori status should be assessed in all patients with peptic ulceration. 4.6.6 Gastric ulcer healing should be confirmed by repeat gastroscopy in 6 to 8 weeks. The responsibility for booking this procedure lies with the team responsible for inpatient care. 4.6.7 Patients who re-bleed after endoscopic treatment should be referred urgently for surgery. Page 9 of 14
4.6.8 Interventional radiology is not immediately available at Salford Royal Hospital. Registrar or consultant referral for transfer to a centre where interventional radiology is available should be considered in patients who re-bleed after endoscopic treatment and in whom surgical management is considered inappropriate by the surgical on-call consultant. 4.7 Management of Variceal UGIB 4.7.1 Band ligation should be used to control oesophageal variceal bleeding. 4.7.2 Balloon tamponade may be required if initial therapy is unsuccessful. This should be used as a bridge to definitive haemostasis either by repeat endoscopy (within 12 hours) or referral to a centre where transjugular intrahepatic portasystemic shunt (TIPSS) is available. 4.7.3 Terlipressin and antibiotics should be given to patients following endoscopic band ligation for oesophageal varices. 4.7.4 Bleeding gastric varices, or gastric varices with stigmata of recent bleeding should be treated with N-butyl-2-cyanoacrylate (fast acting adhesive sold for household use under trade name Super Glue ) injection as per protocol. Glue injection should only take place in a setting where appropriately trained endoscopy assistants are available. Page 10 of 14
Flow Diagram for Management of Acute Non-variceal UGIB RESUSCITATION RISK ASSESSMEMT BLATCHFORD = 0 Stable Patient BLATCHFORD 1 Stable Patient BLATCHFORD 5 Unstable Patient CONSIDER DISCHARGE WITH OUTPATIENT ENDOSCOPY INPATIENT ENDOSCOPY WITHIN 24 HRS ENDOSCOPY IMMEDIATELY AFTER RESUSCITATION SURGICAL OPINION REBLEED HAEMOSTASIS ACHIEVED REFER URGENTLY FOR SURGERY MANAGE ON EAU OR GASTROENTEROLOGY WARD IF SURGERY CONSIDERED INAPPROPRIATE +/- PPI BOLUS FOLLOWED BY 72HR INFUSION +/- H. PYLORI ERADICATION REFER FOR INTERVENTIONAL RADIOLOGY OR MANAGE CONSERVATIVELY Page 11 of 14
Flow Diagram for Management of Acute Variceal UGIB RESUSCITATION RISK ASSESSMEMT TERLIPRESSIN + ANTIBIOTICS BLATCHFORD 1 Stable Patient BLATCHFORD 5 Unstable Patient INPATIENT ENDOSCOPIC VARICEAL BANDING WITHIN 24 HRS ENDOSCOPIC VARICEAL BANDING IMMEDIATELY AFTER RESUSCITATION BLEEDING CONTINUES BALLOON TAMPONADE (SENGSTAKEN TUBE) HAEMOSTASIS ACHIEVED MANAGE ON EAU OR GASTROENTEROLOGY WARD + SECONDARY PROPHYLAXIS (ß BLOCKERS/ELECTIVE OUTPATIENT BANDING PROGRAMME) BLEEDING CONTINUES REFER FOR TIPSS OR MANAGE CONSERVATIVELY HAEMOSTASIS ACHIEVED MANAGE ON CRITICAL CARE UNIT CONSIDER REFERRAL FOR TIPSS OR REPEAT ENDOSCOPY + VARICEAL BANDING (SENGSTAKEN SHOULD BE REMOVED WITHIN 12HRS) Page 12 of 14
Standards (section number should follow on from the preceding section) BSG and NICE guidance June 2012 (Acute upper gastrointestinal bleeding: management, Issued: NICE clinical guidance 141 guidance.nice.org.uk/cg141 NHS). Explanation of terms & Definitions Upper GI Bleed Bleeding originating from the oesophagus, stomach or duodenum Varices Swollen blood vessels in stomach or oesophagus associated with cirrhosis of the liver References and Supporting Documents BSG and NICE guidance June 2012 (Acute upper gastrointestinal bleeding: management, Issued: NICE clinical guidance 141 guidance.nice.org.uk/cg141 NHS). Antibiotics Guidelines: Gastrointestinal Infections 144TD(C)25(D2) Massive Haemorrhage Protocol TC5(08) Roles and responsibilities 5.1 The first clinician to identify a patient as having an acute UGIB will request an endoscopy on Sunrise immediately. GBS should be documented on the request. 5.2 Within normal endoscopy unit hours, the coordinating nurse will review inpatient referrals for endoscopy and schedule patients with acute UGIB to have an endoscopy within the timeframes outlined by this SOP. 5.3 Outwith endoscopy unit working hours the on-call endoscopist should be contacted to discuss unstable patients with acute UGIB and GBS >5. 5.4 A surgical assessment forms a routine part of management planning in unstable patients with suspected non-variceal acute UGIB. 5.5 Anaesthetic assessment is required in all patients where emergency endoscopy in theatres is planned. Page 13 of 14
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