You are on page 1of 8

1

Diagnostic Approach and Management of Patient with Hematemesis


Melena and DD.

Prof Dr Iswan A.Nusi, SpPD.,K-GEH.,FINASIM, FACG.


Gastroenterology and Hepatology Division
Internal Medicine Department of Dr.Soetomo General Hospital/Airlangga University
SURABAYA.

Abstract
Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition that
requires prompt and appropriate management. Upper gastrointestinal bleeding is defined as
bleeding from a source proximal to the ligament of Treitz and can be categorized as either
variceal or nonvariceal. The step-wise management of patients with upper gastrointestinal
bleeding consist hemodynamic status is first assessed, and resuscitation initiated as needed.
Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age,
and laboratory tests.
Pharmacologic management of acute UGIB, described focuses on profound acid
suppression with proton pump inhibitors (PPIs). Gastric acid inhibits platelet aggregation,
impairs clot formation, and promotes fibrinolysis; therefore, inhibiting gastric acid and
raising the intragastric pH to 6 or higher may promote clot formation and decrease the risk of
rebleeding. This is an equivalent of PPIs as an intravenous bolus of 80 mg followed by
continous intravenous infusion of 8 mg/hour for 72 hours, then oral therapy. Somatostatin or
the analog (octreotide) decrease sphlancnic blood flow, gastric acid secretion and pepsin, and
stimulate mucus production. Somatostatin or the analog (octreotide) can be given for variceal
bleeding.

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is defined as bleeding from a source proximal


to the ligament of Treitz. The causes of UGIB could be divided into variceal bleeding
(esophagus and gastric varices) and non-variceal bleeding (peptic ulcer, erosive gastritis,
reflux esophagitis, tumor, etc) (Cappell, 2008; Savides, 2016).
In Indonesia, previous datas showed that approximately 70% of UGIB cases were
caused by rupture of esophageal varices. Despite that, it is expected that improving access to
healthcare for chronic liver disease patient and increasing elderly population will lead to
increase proportion of bleeding due to peptic ulcer (PGI, 2012).
According to Surabaya dr.Soetomo General Hospital datas in 1990, the leading cause of
UGIB was variceal bleeding. A study conducted in 2006 also gave the similar result with
variceal bleeding as the major cause of UGIB in Surabaya dr.Soetomo General Hospital
2

(40,06%). In 2007, the leading cause of UGIB in Surabaya dr.Soetomo General Hospital was
still variceal bleeding (32,24%). However in 2008, the main cause of UGIB in Surabaya
dr.Soetomo General Hospital had shifted with erosive gastritis (42,66%) took over variceal
bleeding position (27,99%), followed by peptic ulcer (11,26%) and malignancy (3,41%)
(Sugihartono, Nusi IA, et al, 2010).
UGIB can be manifested as hematemesis and melena. Hematemesis is vomiting of
coffee-ground blood material resulted from blood reaction with peptic acid. Melena is black-
tarry, sticky and foul smelling stool. Massive bleeding from upper GI tract may not contact
with peptic acid, thus manifests as red blood vomiting and hematochezia (Laine, 2012).
Management of patient with UGIB include medical treatment, endoscopic intervention,
radiologic intervention, and surgery. This paper would discuss over medical treatment..

UGIB Medical Management


General Measure
In evaluating patient with UGIB, the first step is determine bleeding severity. Bleeding
severity could be assessed from hemodynamic status during physical examination, including
blood pressure, heart rate, orthostatic change of blood pressure and heart rate, respiratory
rate, peripheral perfusion, level of consciousness, and urine production (Blecker, 2008;
Cappel, 2008).
In unstable hemodynamic condition, prompt resuscitation is mandatory to stabilize
blood pressure and replace loss of intravascular volume. Presence of resting tachycardia
(tachycardia might be masked by beta blocker consumption), hypotension, and postural
change of vital signs suggest significant loss of blood volume. Reduced urine output and
dryness of mucous membrane should also be noticed. CVP insertion is indicated for elderly
and those with heart disease in order to optimize volume resuscitation (Cappel, 2008;
Albeldawi, 2010).
Oxygen administration is required especially for elderly with heart disease. In those
with anticoagulant, correction of coagulopathy should be done especially if INR more than
1,5, as these subset of patients have high risk for rebleeding (Albeldawi, 2010).
3

Table 1. Correlation of clinical signs with bleeding severity (Cappel,2008)


Clinical signs or amount Severity
Mild Moderate Severe
of blood loss
Blood loss <1L 1-2L ≥ 2L
Blood pressure Normal Normal to borderline Hypotension
Orthostatic hypotension - ± +

Tachycardia Absent or mild Moderate Severe


Skin Warm Moist Cold, clammy
Respiratory rate Normal Normal or slightly Irregular
reduced
Urine production Normal Reduced Minimal
Sensoric Alert or agitated Agitated Confused or drowsy

Nasogastric tube insertion is needed for evaluating UGIB aspirate during initial
examination. If bright red coloured-blood is detected in aspirate, patient requires urgent
endoscopy and further monitoring in intensive care unit. If coffee black-coloured blood is
detected, patient should be admitted to the hospital and undergo endoscopic evaluation within
24 hours. However, the absence of blood in nasogastric aspirate does not rule out the
possibility of UGIB ( Albeldawi, 2010).
If endoscopy can be performed immediately, nasogastric tube is not required for
diagnosis but may offer help for gastric lavage prior to endoscopy. Gastric lavage reduces
gastric distention and has an effect on hemostatic process, despite their role for terminating
bleeding is not proven. Gastric lavage should use room-temperature water since cold water
can prolong bleeding time, reduce gastric wall perfusion, and cause ulceration on gastric
mucosa (Adi, 2006).
After resuscitation, the next step is obtain blood sample for laboratory examination
which includes complete blood count, blood type, coagulation profile, liver function test,
blood urea nitrogen, and electrolytes.
Hematocrite does not drop instantenously during bleeding since at the initial period of
bleeding, the loss of plasma and erythrocyte is proportional. Hematocrite level drops later due
to hemodilution from extravascular fluid, typically occurs 24-72 hours from the onset of
bleeding (Alexander, 2008; Cappel, 2008).
After patient has been stabilized, history taking to identify the cause of UGIB should be
carried out. This includes history of previous UGIB, gastrointestinal complaints,
4

characteristics of UGIB, drugs consumption (NSAID, anticoagulant, traditional drugs),


alcohol consumption, and previous liver disease (Cappel, 2008).
Physical examination must focused to search any sign of chronic liver disease and
portal hypertension (Cappel, 2008).

Figure 1. UGIB management algorithm (Savides, 2016).

Determine risk factor stratification


Various stratification systems were used to determine the patient’s prognosis. Generally,
patient’s prognosis with UGIB is affected by these conditions (PGI, 2012) :
 Age more than 60 years
 Onset of bleeding in the hospital setting
 Presence of comorbidity
 Shock or orthostatic hypotension
 Fresh blood in nasogastric tube
 Coagulopathy
5

 Need for repeated transfusion


 Ulcer on the upper portion of minor curvature (in proximity to left gastric artery)
 Ulcer on posterior duodenal bulb (in proximity to gastroduodenal artery)
 Endoscopic findings of active arterial bleeding or visible vessels

Numerous scoring systems often used, such as Blatchfold risk score (BRS) and Rockall
scoring system (RSS). BRS predicts patient’s prognosis with non-variceal UGIB before
endoscopic treatment (based on clinical and laboratory features alone). BRS score range from
0-23, where most patients with 6 or more points need an intervention action. Whereas RSS is
the most widely used scoring system that able to predict the risk of rebleeding and mortality.
Though, RSS requires endoscopic examination. RSS range from 0-11, where total points 2 or
less is associated with excellent outcome. Other less-used scoring systems are Baylor score
and Cedar-Sinai index. (Bardou 2006; Blecker, 2008; Savides, 2016)

Table 2. Blatchford risk score dan Rockall scoring system (Kuipers, 2010)

UGIB Medical Treatment


One of the UGIB treatment modality is the use of proton pump inhibitor drugs
intravenously. PPI decreases basal acid concentration and secretion by inhibiting hydrogen-
6

potasium adenosine triphosphatase proton pump within parietal cell (Bardou, 2006;
Albeldawi, 2010; Chen, 2011). From metaanalysis, it was known that PPI administration
before or after endoscopy can decrease rebleeding incidence of peptic ulcer, need for
transfusion and endoscopy, length of operation and hospital stay but does not reduce
mortality (Blecker, 2008; Albeldawi, 2010). Currently, PPI drugs in Indonesia are omeprazol,
pantoprazol, and esomeprazol. Initial dose is bolus 80 mg intravenously, continued with 8
mg/kg body weight/hour infusion for 72 hours (Level of Evidence A, class of
recommendation Ia). After patient has been stabilized, PPI could be switched to oral
preparation. In UGIB, administration of antacids, sucralfate, and H2 receptor antagonist may
be given in order to heal the culprit mucosal lesion (Adi, 2006; Cappel, 2008; Albeldawi,
2010).
Somatostatin and its analogue octreotide reduce splanchnic blood flow, pepsin and
gastric acid secretion, and stimulating mucus production. This class of drug has efficacy for
variceal bleeding. Initial somatostatin dose is bolus 250 mcg intravenously, followed by 250
mcg/hour infusion for 12-24 hours or until bleeding stops. Octreotide dose is bolus 100 mcg
intravenously, followed by 25 mcg/hour infusion for 8-24 hours or until bleeding stops (Adi,
2006; Cappel, 2008; Albeldawi, 2010).
In remote hospital without endoscopy facility or in difficult situation to differentiate
variceal bleeding from non-variceal bleeding, it is advisable to consider concurrent
administration of both agents above, PPI and somatostatin and its analogue (octreotide).

Summary
Non-variceal UGIB is an emergency case that requires prompt management. The current
leading cause of UGIB in Dr.Soetomo General Hospital Surabaya is erosive gastritis. Initial
medical treatment for UGIB is the administration of proton pump inhibitor (PPI)
intravenously. PPI decreases basal acid concentration and secretion by inhibiting hydrogen-
potasium adenosine triphosphatase proton pump within parietal cell. The initial dose is bolus
80 mg intravenously, continued with 8 mg/kg body weight/hour infusion for 72 hours then
followed by oral therapy. Somatostatin and its analogue octreotide reduce splanchnic blood
flow, pepsin and gastric acid secretion, and stimulating mucus production. This class of drug
has efficacy for variceal bleeding.

REFERENCES
7

Adi P (2006). Pengelolaan perdarahan saluran cerna bagian atas. Dalam: Buku Ajar Ilmu
Penyakit Dalam edisi IV. Editor: Sudoyo AW, Setyobudi W, Alwi I, K Simadibrata M,
Setiati S. Pusat Penerbitan Departemen FKUI. halm 291-294
Albeldawi MA, Qadeer MA, Vargo JJ (2010).Managing acute upper GI bleeding, preventing
recurrences. Cleveland Clinic Journal of Medicine 77(2): 131-140
Blecker E, Heller J, Scmitz V, Lammert F, Sauerbruch T (2008). Diagnosis and management
of upper gastrointestinal bleeding. Dtsch Arztebl 105 (5): 85-94
Cappel l MS, Friedel D (2008). Initial management of acute upper gastrointestinal
bleeding:from intial evaluation up to gastrointestinal endoscopy. Med.Clin.N Am 92:
491-509
Kuipers EJ (2010). Risk assesment in upper gastrointestinal bleeding. Nature Reviews vol 7:
480-481
Laine L & Dennis MJ (2012). Management of Patients with Ulcer Bleeding. Am J
Gastroenterol no 107:345–360
Perkumpulan Gastroenterologi indonesia (2012). Konsensus Nasional Penatalaksanaan
Perdarahan Saluran Cerna Atas non Varises di Indonesia. Halm 1-21
Savides TJ & Dennis MJ. Gastrointestinal Bleeding. In: Sleisenger & Fordtran’s
Gastrointestinal and Liver Disease 10th ed. Elsevier. pp 297-334
Sugihartono T, O K Hernomo, Nusi IA, Adi P, Setiawan PB, Purbayu H (2010). Endoscopic
finding of upper gastrointestinal bleeding at dr.Soetomo hospital, Surabaya. Folia
Medica Indonesiana 46 (2): 146-149

APPENDAGE
National Concensus of Indonesian Society of Gastroenterology for UGIB management
8