emDOCs Podcast – Episode 126: Upper GI Bleeding Evidence and Controversies Part 2

When is endoscopy recommended?

• Upper GI endoscopy key diagnostic modality with high sensitivity and specificity for diagnosing source of bleeding. Integral to achieving hemostasis and preventing rebleeding. Thus, consult GI for admitted patients with UGIB.
• Risks of endoscopy: aspiration, GI perforation, increased bleeding, and adverse events to sedation.
• Current data suggest endoscopy within 24 hours associated with reduced in-hospital mortality, shorter LOS, and reduced costs in those with non-variceal UGIB.
• Endoscopy within 12 hours has demonstrated conflicting results.
  • 2020 study evaluated endoscopy within 6 hours of GI consultation compared with endoscopy within 24 hours in those with acute UGIB, hemodynamic stability, and Glasgow Blatchford score (GBS) ≥ 12. No difference in mortality, but only a quarter underwent endoscopy within 6 hours, and there were no patients who were hemodynamically unstable.
  • Another RCT evaluating endoscopy within 12 hours compared with after 12 hours for those with UGIB due to confirmed bleeding ulcer found no decrease in bleeding or mortality.
  • Large prospective study with 12,601 patients with UGIB associated with peptic ulcers found higher in-hospital and 30-day mortality in patients undergoing endoscopy within 6 hours, particularly in those who were hemodynamically unstable or had an American Society of Anesthesiologists score ≥ 3.
• Data for variceal UGIB differ.
  • Meta-analysis of 9 studies found patients with variceal UGIB undergoing early endoscopy within 12 hours had reduced mortality compared to delayed endoscopy after 12 hours, with no difference in rebleeding.
• Guidelines: ACG recommends performing endoscopy within 24 hours of admission or patient presentation in patients with non-variceal bleeding who are hemodynamically stable; ESGE guidelines and ICG recommend performing endoscopy within 24 hours but after resuscitation in those with non-variceal bleeding.
  • ACG and ESGE guidelines do not recommend urgent endoscopy (≤12 hours) in patients with non-variceal UGIB, as there is no improvement in patient-centered outcomes. ICG does not make a recommendation before or against endoscopy within 12 hours in those with non-variceal bleeding.
  • Guidelines for those with variceal bleeding differ; these patients should undergo endoscopic evaluation within 12 hours. In patients with variceal bleeding, guidelines recommend endoscopy as soon as possible after resuscitation.
• Must resuscitate prior to endoscopy.
• Take-home: Data and guidelines suggest that while endoscopy should be obtained within 24 hours in those with non-variceal UGIB, emergent resuscitation prior to endoscopy is necessary, along with GI consultation in the ED. In variceal bleeding, endoscopy within 12 hours (or sooner) is recommended after resuscitation. Evidence suggests that a normal hemoglobin or platelet count is not necessary prior to endoscopy. Antiplatelet agents, anticoagulants, and a defined INR threshold should not be used as contraindications.

What are other interventions beyond endoscopy?

• For UGIB that fails other therapies including endoscopy, particularly in those with peptic ulcer disease, transcatheter arterial embolization (TAE) or surgery may be necessary.
  • Meta-analysis including 13 studies comparing TAE versus surgery in patients with UGIB who failed endoscopy found no difference in mortality (OR 0.77, 95% CI 0.50-1.18), but fewer major complications (OR 0.45, 95% CI 0.30-0.67) and reduced LOS (8 vs. 16 days) in TAE. There was higher risk of bleeding with TAE (OR 2.44, 95% CI 1.77-3.36).
• TAE is a viable option for control of UGIB.
• If interventional radiology available, consult both IR and surgical specialist. Specific modality should be based on the hemodynamics, local expertise, and patient comorbidities. If TAE is an option, CTA can help to assist with localization of the bleeding. With appropriate localization, TAE successful in approximately 95% of patients.
• For patients with variceal bleeding who continue bleeding despite medical therapy while waiting endoscopy, a balloon tamponade device can be used for short-term bleeding control; there are complications and a risk of rebleeding when the balloon is deflated.
• Three balloon tamponade devices: Sengstaken-Blakemore tube (with a gastric and esophageal balloon and single gastric suction port), Minnesota tube (gastric and esophageal balloon with esophageal and gastric suction ports), and Linton-Nachlas tube (gastric balloon).
  • These devices are effective in 30-90% of patients with variceal bleeding.
  • Patients should be intubated prior to balloon placement.
  • After the device is placed, it can remain in place for 24 hours, but gastric balloon needs to be deflated every 12 hours to assess for rebleeding. If bleeding recurs upon deflation, the balloon can be reinflated.
  • Balloon tamponade is only a temporizing measure; relative contraindications include recent esophageal or gastric surgery and esophageal stricture.
• Transjugular intrahepatic portosystemic shunt (TIPS) is an option for patients with severe, continued variceal bleeding and functions as a surgical portacaval shunt. 90-100% success rate in decreasing bleeding, but may increase the risk of encephalopathy.

What airway considerations are necessary in those with UGIB?

• Challenging airway. If y intubating, must manage complications like an obstructed view due to the blood or vomit; risk of aspiration, hemodynamic instability, comorbidities, and blood or body fluid exposure.
• Avoid endotracheal intubation if at all possible. Prophylactic intubation in UGIB is associated with greater risk of mortality, pneumonia, hospital LOS, and cost.
• ESGE recommends against routine endotracheal intubation prior to upper endoscopy.
• Intubation necessary in those with respiratory distress/failure, decreasing level of consciousness, continued ongoing hematemesis, inability to adequately control the airway, high risk of continued deterioration, aspiration, and need for further intervention like a GI tamponade device or endoscopy).
• Resuscitate prior to intubation and have double setup for cricothyrotomy.

Table. Approach for endotracheal intubation in those with UGIB.

Which decision tools are effective at risk stratifying patients with UGIB?

• Tools: GBS, AIMS65 score, ABC score, Canada–United Kingdom–Adelaide (CANUKA) score, and the Rockall score.
• Two versions of the Rockall score: pre-endoscopy and post-endoscopy; pre-endoscopy score is the most relevant for the emergency clinician and includes age, shock, and comorbidities.
• GBS is the most commonly used score and have been validated several times. GBS ≤ 1 over 98% sensitive in predicting low risk UGIB. Multiple studies comparing GBS with other scores suggest GBS is more accurate in determining who is low risk and predicting mortality and need for in-hospital intervention. Modified version of GBS removes melena, recent syncope, history of liver disease, and the presence of heart failure. Several studies suggesting similar accuracy between the original and modified versions of GBS.
• AIMS65 was derived in 2011 to predict mortality and can also be used prior to endoscopy. One study suggests AIMS65 may be better at predicting in-hospital mortality, intensive care unit admission, and hospital LOS, while the GBS is better at predicting the need for transfusion.
• ABC score has demonstrated good performance in predicting mortality.
• Most recently evaluated score is the CANUKA scoring system, derived in 2019. A second study evaluating the CANUKA score found those with a score < 4 had no adverse events, and no patient with a score < 6 died. Third study found GBS ≤ 1, modified GBS of 0, and CANUKA ≤ 2 had high sensitivity in determining low risk, with no patient deaths.
• 2016 systematic review compared the GBS, Rockall, and AIMS65 scoring systems. GBS score had better predictive value in determining low risk for 30-day adverse events.
• 2023 meta-analysis comparing risk scores for UGIB included 38 studies evaluating the GBS, clinical Rockall score, CANUKA, AIMS64, and ABC score. GBS score with a threshold of ≤ 1 was the best discriminator in predicting low risk (including mortality; rebleeding; and need for endoscopic, surgical, or radiologic intervention).
• Guidelines: ACG, ESGE, and ICG suggest using a GBS score of ≤ 1 over other scores to identify UGIB patients at very low risk of mortality or rebleeding and who may be appropriate for outpatient management.
• Do NOT rely on these scores alone.
  • Severe or recurrent bleeding, hemodynamic instability, significant comorbidities, suspected high risk bleeding sources (e.g., varices, ulcer, Dieulafoy’s lesion), or inability to follow up should be admitted.
  • Consider discharge with follow up if these are not present and the patient can be stratified as low risk (e.g., GBS of ≤1).

Summary:

• Endoscopy is recommended within 24 hours for those with non-variceal bleeding for diagnosis and management, though this should be completed sooner in those with variceal bleeding.
• If endoscopy fails to achieve hemostasis, TAE or surgical intervention may be necessary.
• Endotracheal intubation may be necessary in select patients but is not recommended routinely.
• GBS ≤ 1 suggests the patient is at low risk of adverse events, but these risk scores should never replace clinical judgment.

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