Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (32 page)
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Colin J. McKay and
James Lau
A major audit of upper gastrointestinal (UGI) bleeding in the UK carried out over 15 years ago reported an incidence of 103 cases per 100 000 adults per year.
1
A much higher incidence was reported in an audit from the West of Scotland, which found 172 cases per 100 000.
2
The difference was thought to be due to regional variation in deprivation and possible
Helicobacter pylori
prevalence. Whatever the actual incidence at regional level, UGI bleeding remains a significant health problem and in Scotland alone accounts for approximately 7000 hospital admissions each year. Overall mortality from an episode of UGI bleeding was 14% in the UK study
1
and 8% in the study from the West of Scotland,
2
and both demonstrated a marked increase in mortality if bleeding occurred following hospitalisation with another complaint (33% and 44% in the respective studies). A more recent audit
3
covering patients admitted to UK hospitals during a 2-month period in 2007 demonstrated a marked reduction in the proportion of patients undergoing surgery, as well as an increase in the proportion of patients admitted with variceal bleeding. Overall mortality had fallen slightly at 10%, compared with 14% in the earlier UK audit, and the mortality of 26% for inpatients was also lower than in the pevious study. However, mortality in patients admitted with peptic ulcer bleeding had fallen from 8.8% to 5.8% and the overall reduction in mortality from 14 to 10% occurred despite the increase in incidence of variceal bleeding. Mortality is now rare in the absence of comorbidity. The typical patient with severe peptic ulcer bleeding is now elderly, often suffering medical comorbidity and taking antiplatelet therapy. Such patients are at greater risk of death despite skilled intervention and are less able to withstand surgery should this be necessary. Although the need for surgical intervention is now much reduced with the widespread availability of skilled endoscopic haemostasis, mortality following surgery remains high. In the recent UK audit, postoperative mortality was 30% and, while this is likely to reflect the fact that surgery has become a last resort in patients who are often elderly and suffering from other conditions, there are inevitable concerns about the availability of appropriate expertise in the management of what has become an uncommon surgical emergency. As a result alternatives to surgical intervention are increasingly being employed and will be discussed in this chapter.
In the Rockall study
1
only 4% of patients had UGI bleeding due to varices, with the majority (35%) being attributed to peptic ulcer disease. Of some concern was the 25% of patients in this study where no cause for bleeding was identified at all, particularly as this group had a mortality of 20%. Very similar figures were reported in the Scottish study.
2
Of those patients with a diagnosis, approximately 25% were due to duodenal ulcer and 25% to peptic ulceration in the stomach, oesophagus or a combination of sites. The remainder were due to a number of other conditions, including oesophagitis, gastritis and duodenitis, with 10% of cases explained by malignancy or Mallory–Weiss syndrome (
Table 7.1
). In the most recent UK audit, the proportion of patients with variceal bleeding had increased to 11%, whereas the overall proportion with peptic ulcer remained unchanged.
Table 7.1
Endoscopic diagnoses to patients who presented with acute upper gastrointestinal bleeding in the 2007 UK Audit.
| Endoscopic diagnoses | Total number of patients (5004) % (n) |
| Peptic ulcer | 36 (1826) |
| Varices | 11 (544) |
| Malignancy | 3.7 (187) |
| Oesophagitis | 24 (1177) |
| Gastritis/ erosions | 22 (1091) |
| Erosive duodenitis | 13 (640) |
| Mallory-Weiss Tear | 4.3 (213) |
| Others including vascular ectasia | 2.6 (133) |
| No abnormality seen | 17 (865) |
Modified from Hearnshaw S et al. Gut 2011; 60: 1327-1335
Patients with acute UGI bleeding present with haematemesis, melaena or a combination of the two. Haematemesis may be defined as the vomiting of blood from the upper gastrointestinal tract and is indicative of significant bleeding from a site in the oesophagus, stomach or duodenum. Melaena is the passage of black, tarry stools and usually indicates a bleeding site in the upper gastrointestinal tract, although bleeding from the small bowel or even the right colon may present in a similar way, depending on speed of passage. Coffee-ground vomiting (the vomiting of black, particulate material that tests positive for blood) is not indicative of active bleeding. Presentation with haematemesis is associated with an increased risk of mortality compared with melaena or coffee-ground vomiting.
4
Patients with upper gastrointestinal blood loss may occasionally present with frank rectal bleeding (haematochezia), but this is indicative of major blood loss and, not surprisingly, is associated with an increased need for transfusion, surgery and mortality.
5
A good example of this would be a patient who has previously undergone aortic aneurysm surgery who subsequently develops an aortoduodenal fistula.
Many patients with UGI haemorrhage have trivial bleeding, require no intervention and can safely be discharged early. Others, however, have catastrophic bleeding and many lie between these two extremes. On initial assessment, differentiation between patients can sometimes be difficult. Two separate studies have assessed the initial, pretreatment risk factors in an attempt to enable triage of patients to appropriate early endoscopy, observation or even non-admission. In the English audit discussed above, Rockall and colleagues identified risk factors for mortality.
5
Patients with an initial score of zero (i.e. age < 60, no tachycardia, no hypotension and no comorbidity) had very low mortality, although in a subsequent study 18% of patients with an initial Rockall score of zero required further intervention. Assessment of the re-bleeding risk therefore requires the full Rockall score, which necessitates endoscopic assessment. This is discussed below.
In contrast, a scoring system was developed in the West of Scotland, the aim being to allow early assessment of the need for intervention rather than risk of death.
6
The Glasgow Blatchford Score (GBS) performed significantly better than the Rockall score at predicting the need for intervention and has now been validated in prospective studies from the UK
7
and Hong Kong.
6
In particular, the GBS is the better scoring system for predicting low-risk patients who can be safely discharged. The proportion of patients with UGI haemorrhage who fulfil these low-risk criteria (i.e. a GBS of 0) is, however, low (4.6% in the Hong Kong study). The proportion of patients who require endoscopic therapy increases with higher scores. There remains a small but significant proportion of patients with low to moderately high scores who require endoscopic therapy and it is difficult to define a cut-off score beyond which urgent endoscopy becomes mandatory.
Full assessment of mortality risk demands endoscopic determination of the cause of bleeding and assessment of the appearance of any ulcer present. These findings are incorporated into the full Rockall score. This composite Rockall system has been validated in prospective studies,
8
–
10
but is more accurate in predicting mortality than the risk of re-bleeding
8
,
9
(
Table 7.2
).
Table 7.2
Rockall score for predicting risk of re-bleeding or death In non-variceal UGI haemorrhage
IHD, ischaemic heart disease; SBP, systolic blood pressure; SRH, stigmata of recent haemorrhage.
Reproduced from Rockall TA, Logan RFA, Devlin HB et al. Variation in outcome after acute upper gastrointestinal haemorrhage. Lancet 1995; 346(8971):346–50. With permission from Elsevier.
A GBS of 0 on presentation identifies a low risk group of patients who may be safely discharged without the need for urgent UGI endoscopy.
A full Rockall score should be calculated for all patients with UGI bleeding following initial endoscopic assessment.
While it may be appropriate to consider discharge for young patients with no haemodynamic compromise and a GBS of zero, particularly where there has been no witnessed frank haematemesis, most patients with a history of UGI bleeding will be admitted for observation and endoscopy. This will entail insertion of a large-bore cannula, administration of prewarmed crystalloid or colloid as required and immediate blood samples taken for crossmatch, biochemistry, full blood count, coagulation screen and arterial blood gases. There is some evidence that admission to a dedicated UGI bleeding unit is associated with a reduction in mortality.
11
Such a unit requires a 24-hour on-call service for immediate endoscopy if required and early (within 24 h) consultant-led endoscopy for all patients. Indications for urgent (out-of-hours) endoscopy vary, but the main factor determining the degree of urgency is the necessity for endostasis. Therefore, patients with evidence of continuing haemorrhage, declared either by continuing haematemesis or haemodynamic instability despite initial fluid resuscitation, require emergency endoscopy with a view to endostasis. Repeated ‘coffee-ground’ vomiting or melaena in a haemodynamically stable patient are of less urgent concern. Most stable patients will undergo UGI endoscopy within 24 h (usually on the morning after admission). In such patients the purpose of endoscopy is twofold: firstly, patients with minor bleeds undergo full diagnostic assessment and if considered at low risk of re-bleeding can be discharged home; secondly, to identify the group of patients who have significant lesions and who require endoscopic therapy to reduce the risk of re-bleeding. This will be discussed in the next section.
In those patients who have evidence of haemodynamic compromise, initial resuscitation should follow the appropriate guidelines.
11
A Cochrane review of 55 trials found no evidence of any benefit of administering colloid rather than crystalloid solutions during resuscitation in critically ill patients.
12
As colloid solutions are more expensive, initial resuscitation with appropriate crystalloids is recommended.
Red cell replacement is likely to be required when 30% or more of the blood volume is lost. This can be difficult to assess, particularly in young patients, and clinical assessment of blood loss, coupled with the response to initial volume replacement, must guide the decision on the necessity of transfusion. Haemoglobin levels are a poor indicator of the degree of acute blood loss. It should very rarely be necessary to administer unmatched blood to such patients, but group-specific blood may be required in life-threatening haemorrhage. In the majority of patients there is usually sufficient time to allow full compatibility testing before transfusion. In patients with evidence of continuing haemorrhage, however, arrangements for emergency endoscopic intervention must be made in parallel with resuscitation.
Administration of platelets should aim to maintain a platelet count of more than 50 × 10
9
/L, but in practice a platelet transfusion should be triggered by a count of less than 75 × 10
9
/L in a patient with ongoing haemorrhage, and may be anticipated in a patient who has required more than two blood volumes of fluid/blood replacement. Platelet therapy may be required in the presence of a normal platelet count where a patient has been receiving antiplatelet therapy.
Coagulation factors are likely to be required when more than one blood volume has been lost. These are most commonly given in the form of fresh frozen plasma (FFP). The use of platelets, FFP and other agents such as recombinant factor VIIa should be guided by local protocols and early involvement of a haematologist.
Upper gastrointestinal endoscopy is the mainstay of investigation and management of UGI bleeding, but there may also be a role for early treatment with acid suppression therapy. In vitro studies have shown that, at pH < 6, platelet aggregation and plasma coagulation are markedly reduced,
13
a situation exacerbated by the presence of pepsin. It is therefore reasonable to expect acid suppression therapy to promote clot formation and stabilisation. Six randomised trials comparing pre-endoscopy proton-pump inhibitor (PPI) therapy with histamine-2 receptor antagonist or placebo were analysed in a Cochrane review.
14
No significant impact of PPI therapy was demonstrated on mortality, surgery or re-bleeding rates. There was, however, a reduction in the proportion of patients with stigmata of recent haemorrhage at the time of endoscopy, and a reduction in the requirement for endoscopic therapy at the index endoscopy. While these findings may suggest that pre-endoscopy PPI therapy is warranted, there was no evidence of a reduction in any of the clinically significant parameters. In a large, single-centre, randomised study,
15
pre-endoscopy intravenous omeprazole infusion was associated with a reduction in the incidence of active bleeding and significant reduction in the necessity for endoscopic intervention. However, no difference was observed for re-bleeding, surgery or mortality rates, which were observed in 3%, 2% and 2% of patients, respectively. An accompanying cost-effective analysis concluded that the strategy of pre-emptive use of PPI infusion was cost-saving, probably because of reduced endoscopic therapy and hospitalisation.
16
It therefore seems reasonable to propose pre-endoscopic PPI therapy in patients admitted with UGI bleeding, but this should not delay or act as a substitute for early endoscopic intervention. There is no evidence to support the use of other agents such as somatostatin, octreotide or vasopressin in the pre-endoscopy setting, except where variceal bleeding is suspected.
Pre-endoscopy treatment with PPIs is recommended as it reduces the number of actively bleeding ulcers and increases the number of clean-based ulcers seen at the time of endoscopy.
14
Early use of PPI reduces the need for endoscopic intervention and hospitalisation.