Gastrointestinal haemorrhage: haematemesis and melaena

Haematemesis: vomiting fresh red blood.
Coffee-ground vomiting: vomiting of altered black blood.
Melaena: the passage of black tarry stools.
Bleeding may be from oesophageal varices or from other sites (non-variceal bleeding).

Acute upper gastrointestinal (GI) bleeding affects 50 to 150 per 100,000 of the population each year and accounts for a substantial proportion of all blood used in UK hospitals. In the UK in 1995, mortality was reported to be 11% in patients admitted to hospital because of bleeding and 33% in those who developed gastrointestinal bleeding while hospitalised for other reasons. In the west of Scotland in 1997, the corresponding figures were 8.2% and 43%. Most deaths are in elderly patients with significant co-morbidity. Mortality is reported to be lower in specialist units where there is close medical/surgical/endoscopic cooperation and adherence to management protocols. This section is intended only to give an overview of transfusion, which is just one part of the overall management of patients with GI haemorrhage (Tables 10 and 11).(PMID9329304)(PMID2351300)(PMID8912283)(PMID15254304)(PMID7627034)

Table 10 Use of fluids and transfusion in GI bleeding in chronic liver disease (with variceal bleeding)

Features

Transfusion management

End points

Bleeding is often but not always from oesophageal varices and is often severe. Other causes such as peptic ulcer are not uncommon and must be excluded.

Bleeding from varices usually recurs if there is no intervention to control the varices or to reduce portal pressure. The prognosis depends on the severity of the liver disease.

Hepatic failure may follow variceal bleeding, but usually recovers if bleeding can be stopped and recurrence prevented.¹

Insert one or two large bore cannulas. A central line may be indicated.

Ensure red cells are available quickly; use local emergency transfusion protocol: order 4−6 units.
Crystalloids should be used carefully. Saline should be avoided as sodium retention is usual and leads to ascites.

Systolic pressure
> 100 mmHg

Urine output > 40 ml/hr

CVP 0−5 mmHg
(not higher)

Haemoglobin up to 90 g/l

Thrombocytopenia is usual. Provided the platelet count is above 50 x 10⁹/l, bleeding is unlikely to be controlled or prevented by platelet transfusion.

Normal (i.e. pre-bleed) systolic blood pressure is often lower than in non-cirrhotic patients.

Platelet transfusion is rarely needed. If there is continued bleeding with a platelet count below 50 x 10⁹/l, platelet transfusion may be considered in an effort to control variceal bleeding.

Platelet count may show little increment following platelet transfusion in patients with splenomegaly.

Deficiency of coagulation factors is frequent (except fibrinogen and factor VIII).

Coagulation factor concentrates may be indicated. Seek expert advice as some of the products have a risk of thrombogenicity, especially in patients with liver disease.

Fresh frozen plasma is indicated only if there is documented coagulopathy, e.g. INR >2.0.

Keep INR < 2.0 if possible. Complete correction is rarely possible with FFP due to the large volume needed.

Giving red cells to try to raise Hb towards normal values may raise portal venous pressure, since blood volume is often increased. Over-transfusion may contribute to rebleeding.

Provided blood volume is replaced and cardio-respiratory function was previously adequate, haemoglobin of 90 g/l appears to be adequate.

Transfuse red cells to approach but not exceed end point of 90 g/l.

Note:

This table is based on the protocol used by the Gastrointestinal Bleeding Unit, Royal Infirmary, Aberdeen. (PMID8912283)

[Table 10 resources: View large format or download as Word^™ document]

Table 11 Use of fluids and blood components in acute non-variceal gastrointestinal bleeding

Severity	Clinical features	IV infusion	End point
Severe	History of collapse and/or shock − systolic BP < 100 mmHg − pulse > 100/min	Replace fluid rapidly Ensure red cells are available quickly; use local emergency transfusion protocol Transfuse red cells according to clinical assessment and Hb/Hct	Maintain urine output > 40 ml/hour systolic BP > 100 mmHg haemoglobin > 90 g/l
Significant	Resting pulse > 100/min and/or haemoglobin < 100 g/l	Replacement fluid Order compatible red cells (four units)	Maintain haemoglobin > 90 g/l
Trivial	Pulse and haemoglobin normal	Maintain intravenous access until diagnosis is clear Send patient sample for red cell group and antibody screen	Recheck haemoglobin at 24 hours to reassess blood loss
No evidence of bleeding	May have 'coffee grounds' or altered blood in vomitus. Faecal occult blood negative.
Note: This table is based on the protocol used by the Gastrointestinal Bleeding Unit, Royal Infirmary, Aberdeen. (PMID8912283)

[Table 11 resources: View large format or download as Word^™ document]

Transfusion management

Early recognition of significant blood loss is important. In clinical practice, it is commoner to see patients who have been under-transfused than over-transfused. It is essential to pay attention to and act on recordings of pulse rate and blood pressure. In a fit patient without cardiac disease, persistent tachycardia − even if blood pressure is maintained − is likely to indicate continuing blood loss.

All patients require large-bore intravenous cannulas. Central venous pressure monitoring is valuable in major haemorrhage or if there is cardio-respiratory disease.

Haemoglobin concentration − interpretation

The haemoglobin can underestimate the extent of blood loss in cases of acute haemorrhage before haemodilution has occurred, or can overestimate it if the patient is already anaemic from chronic blood loss.

If liver disease is suspected (e.g. oesophageal varices)

The platelet count and prothrombin time should be checked and correction with blood components may be indicated. It is not necessary to check clotting screen routinely in every case of GI haemorrhage.

Guidelines for management can be found at the BSG website:

Management of upper GI bleeding and

Management of bleeding in patients with oesophageal varices

Do:

group and save all patients
act on vital signs
use large-bore cannulas
use CVP access in high risk patients
correct coagulopathy in patients with cirrhosis.

Don’t:

rely on Hb alone to guide red cell transfusion.