An upper GI bleed is managed by resuscitating first, scoring with the Blatchford score at first assessment and the full Rockall score after endoscopy, and getting endoscopy immediately after resuscitation if the patient is unstable or within 24 hours otherwise. NICE CG141, last updated 25 August 2016, sets those rules and separates variceal from non-variceal treatment. At the CT1 anaesthetics interview the added question is whether the airway needs protecting before the scope.
Key takeaways
- Score everyone: Blatchford at first assessment, full Rockall after endoscopy; consider early discharge if the pre-endoscopy Blatchford is 0 (NICE CG141)
- Endoscopy immediately after resuscitation for unstable patients with severe bleeding, within 24 hours of admission for everyone else
- Platelets if actively bleeding with a count below 50; fresh frozen plasma if actively bleeding with PT, INR or APTT above 1.5 times normal; cryoprecipitate if fibrinogen stays below 1.5 g/L
- Prothrombin complex concentrate for warfarin patients who are actively bleeding; andexanet alfa is a NICE-appraised option for apixaban or rivaroxaban
- No PPI before endoscopy for suspected non-variceal bleeding; PPI after endoscopy if stigmata of recent haemorrhage are seen
- Suspected varices: terlipressin and prophylactic antibiotics at presentation, band ligation for oesophageal varices, TIPS if not controlled
How do you recognise an upper GI bleed?
An upper GI bleed presents with haematemesis, coffee-ground vomit or melaena, and the severity is read from the circulation rather than the vomit bowl. Tachycardia, a narrow pulse pressure, postural drop and cool peripheries mark the patient who is losing volume.
The haemoglobin can be normal early because the patient has lost whole blood, so a reassuring first result does not mean a small bleed. Say that; it shows you understand what the number measures.
The history that changes management is liver disease or alcohol excess, which raises varices; NSAIDs, aspirin, clopidogrel and anticoagulants; and previous ulcer disease.
What do you do first?
The first actions in an upper GI bleed are ABCDE with two large-bore cannulae, bloods including a group and crossmatch, clotting and a venous gas, and a call to the on-call endoscopist and your senior. CG141 puts risk scoring alongside resuscitation, not after it.
- Airway: a patient vomiting blood with a reduced conscious level is an aspiration risk, and that is your call as the anaesthetist
- Breathing: high-flow oxygen, saturations, respiratory rate
- Circulation: access, bloods, crystalloid while blood is prepared, activate the major haemorrhage protocol if bleeding is massive
- Disability and exposure: conscious level, signs of chronic liver disease, a rectal examination for melaena
CG141 says to transfuse patients with massive bleeding with blood, platelets and clotting factors in line with the local massive bleeding protocol. In practice that means naming the protocol and the person who activates it.
How do you risk assess, and what do the scores do?
Risk assessment in upper GI bleeding uses two formal scores, according to CG141: the Blatchford score at first assessment and the full Rockall score after endoscopy. The Blatchford score uses clinical and laboratory findings without endoscopy, so it can be done in the emergency department.
CG141 says to consider early discharge for patients with a pre-endoscopy Blatchford score of 0. The number is 0, not 0 to 1, and it is one of the figures the first tranche of this library got wrong before checking.
The Rockall score adds the endoscopic findings and predicts rebleeding and mortality, which is why it is calculated after the scope rather than before it.
When do you transfuse, and what?
Transfusion decisions in upper GI bleeding are based on the full clinical picture, and CG141 warns that over-transfusion may be as damaging as under-transfusion. The component thresholds it gives are specific.
- Platelets: offer if actively bleeding and the count is below 50 x 10^9/L; do not offer to stable patients who are not bleeding
- Fresh frozen plasma: offer if actively bleeding and the prothrombin time, INR or APTT is more than 1.5 times normal
- Cryoprecipitate: add if fibrinogen remains below 1.5 g/L despite fresh frozen plasma
- Prothrombin complex concentrate: offer to patients on warfarin who are actively bleeding
- Recombinant factor VIIa: not used unless all other methods have failed
For direct oral anticoagulants, CG141 points to the MHRA list of reversal agents and to NICE technology appraisal TA697, which recommends andexanet alfa as an option for life-threatening gastrointestinal bleeding on apixaban or rivaroxaban.
When is endoscopy done?
Endoscopy is done immediately after resuscitation in unstable patients with severe acute upper GI bleeding, and within 24 hours of admission for everyone else, according to CG141. The word is after resuscitation, not instead of it.
For the anaesthetic CT1 the question underneath is whether the endoscopy needs a protected airway. An obtunded patient, ongoing haematemesis, or a variceal bleed heading for theatre or interventional radiology all raise that question, and the answer is a senior anaesthetist in the room.
CG141 also asks units seeing more than 330 cases a year to run daily endoscopy lists, which is why the 24-hour target is achievable in a district general hospital.
How is non-variceal bleeding treated?
Non-variceal bleeding is treated endoscopically with a mechanical method such as clips with or without adrenaline, thermal coagulation with adrenaline, or fibrin or thrombin with adrenaline. CG141 says adrenaline is not used as monotherapy.
Proton pump inhibitors are not offered before endoscopy to patients with suspected non-variceal bleeding, but are offered after endoscopy to those with stigmata of recent haemorrhage. The pre-endoscopy PPI is the commonest wrong answer in this station.
If bleeding recurs, CG141 offers repeat endoscopy with a view to further treatment or emergency surgery, and interventional radiology for unstable patients who rebleed after endoscopic treatment, with urgent surgery if radiology is not promptly available.
How is variceal bleeding treated?
Variceal bleeding is treated with terlipressin at presentation, stopped after definitive haemostasis or after 5 days, and prophylactic antibiotics at presentation, according to CG141. Both start on suspicion, before the scope confirms varices.
Oesophageal varices are treated with band ligation, and a transjugular intrahepatic portosystemic shunt is considered if banding does not control the bleeding. Gastric varices are injected with N-butyl-2-cyanoacrylate, with TIPS if that fails.
These patients are often encephalopathic, coagulopathic and aspirating, which is the combination that brings the anaesthetist to the endoscopy suite. Saying that the airway decision is made with a senior colleague before the procedure starts is the judgement being marked.
What happens to aspirin, NSAIDs and clopidogrel?
Low-dose aspirin for secondary prevention is continued once haemostasis is achieved, other NSAIDs including COX-2 inhibitors are stopped during the acute phase, and clopidogrel is discussed with the relevant specialist and the patient. That is the CG141 sequence.
Stopping aspirin in a patient with a recent coronary stent trades a bleed for a thrombosis, which is why the guideline separates the drugs rather than stopping everything.
Which traps catch candidates?
The upper GI bleed traps at interview are the pre-endoscopy PPI, the reassuring haemoglobin, and the endoscopy called before the patient is resuscitated. Each has a CG141 line against it.
- Giving a PPI before endoscopy for suspected non-variceal bleeding
- Quoting a Blatchford of 0 to 1 for discharge: it is 0
- Transfusing platelets to a stable patient who is not bleeding
- Forgetting terlipressin and antibiotics at presentation when liver disease is in the history
- Not addressing the airway in a vomiting, drowsy patient before the scope
What is the interviewer listening for?
In an upper GI bleed scenario the assessors are listening for resuscitation with a named protocol, the two scores in the right order, the endoscopy timing, and the airway decision made with a senior.
- Two large-bore cannulae, crossmatch, and the major haemorrhage protocol named
- Blatchford now, Rockall after the scope, 0 for early discharge
- Immediately after resuscitation if unstable, within 24 hours otherwise
- Terlipressin and antibiotics on suspicion of varices
- Who protects the airway, and when
How this comes up at the CT1 anaesthetics interview
Upper GI bleeding comes up in the clinical judgement station as a call from the endoscopy suite or the ward: a patient with known cirrhosis is vomiting blood and the gastroenterologist wants to scope now. The station is one of two 15-minute stations, each marked out of 50, with 60 out of 100 appointable.
The follow-up tests working under pressure: the endoscopist is pushing to start, the patient's saturations are falling, and you are the only anaesthetist free. anaestheticinterview's bank of 340 questions includes an upper GI bleed scenario with AI-marked spoken practice, so the CG141 sequence can be rehearsed against the clock.