Management of complicated PUD

Resuscitation

Patients who are haemodynamic unstable need urgent resuscitation and gastroenterology or surgical review.

• Move to Resus area
• Oxygen via 15L NRB mask
• Insert 2 x large bore cannula
• Take bloods including cross-match and coagulation screen
• Consider intravenous fluids or blood products and regularly reassess
• Catheterise to monitor input/output
• Urgent referral to gastroenterology or surgical team.
• Consider Critical Care

Haemorrhage

Bleeding peptic ulcers account for 40-60% of acute upper gastrointestinal bleeds (UGIB). UGIBs range from small bleeds in haemodynamically stable patients, to large exsanguinating bleeds that require urgent endoscopic treatment. 10% of patients will require urgent angiography and embolization or surgery for bleeding despite endoscopic intervention [32].

Clinical features

• Haematemesis or coffee ground vomiting
• Maleana
• Postural hypotension or collapse
• Anaemia
• Raised urea

Initial Management of Unstable Upper Gastrointestinal Bleed

• Resuscitation with crystalloid solution, aiming for a heart rate < 100 bpm and a systolic blood pressure > 100mmHg to avoid dislodging a developing clot.
• Transfusion should be limited, with a target haemoglobin of > 70g/L (or > 90g/L in unstable coronary artery disease) as this is associated with reduced mortality [33].
• Correct coagulopathy:
  • Transfuse platelets if actively bleeding and platelet count < 50 x 109/L. ◦ Fresh frozen plasma (FFP) if actively bleeding and INR > 1.5.
  • If fibrinogen remains < 1.5g/L despite FFP, offer cryoprecipitate.
  • If taking Warfarin and actively bleeding offer vitamin K and FFP or prothrombin complex concentrate (PCC) according to local policy.
  • If taking a DOAC and actively bleeding, discuss with Haematology and consider PCC. If taking Dabigatran, discuss the use of Idarucizumab.
• Urgent endoscopy

The Halt-It trial showed tranexamic acid did not reduce mortality in patients with UGIB but recorded an increased incidence of venous thromboembolic events and seizures in the treatment group compared to controls [30].

Initial management of stable Upper Gastrointestinal Bleed

For stable patients several risk stratification tools are available to assess disease severity, risk of complications, and mortality. The most commonly used are:

• Rockall score. A full Rockall score requires endoscopy findings, but a modified pre-endoscopy score can be used as a marker for severity in the UK. A pre-endoscopy Rockall score of 0 equates with a mortality of 0.2%, a score of 3 with a mortality of 11% and a score of 7 with a 50% mortality.
• Glasgow-Blatchford score. The Glasgow-Blatchford score can be calculated in the emergency department and does not require endoscopy findings.
• A Rockall or Glasgow-Blatchford score of 0 accurately identifies low-risk patients who can be managed on an out-patient basis.

Many stable patients with an UGIB will also be taking anti-platelet or anti-thrombotic medication. Current data on how best to manage these patients is limited and decisions often need to be tailored to individual patients, based on the severity of bleeding and the risk of thromboembolism. This may require discussion with Cardiology or Stroke Teams.

• Continuing aspirin after an UGIB doubles the risk of recurrent bleeding
• Patients receiving dual anti-platelet therapy for drug-eluting stent should avoid stopping both anti-platelet drugs even for a brief period due to the high risk of stent thrombosis

The use of intravenous proton pump inhibitors (PPIs) is common but controversial. Maintaining a neutral gastric pH seems to improve clot stability. There is some evidence that when PPIs are given before endoscopy, they reduce the need for treatment during endoscopy [2]. However, there is no evidence they improve mortality or re-bleeding rates, so NICE advises against giving PPIs before endoscopy. PPIs are recommended post-endoscopy [20].

Definitive management

Endoscopy within 24 hours provides prognostic information and effective therapy, usually by direct injection of adrenaline 1:10,000. If there are high-risk stigmata (i.e. blood in lumen or visible vessel), dual- or triple-therapy may be considered, which consists of adrenaline, mechanically clipping the vessel +/- heat application (either by heater probe, Argon plasma coagulator or multipolar probe). In a meta-analysis of randomised controlled trials, endoscopic treatment reduced re-bleeding, surgery and mortality. Endoscopy also identified low-risk patients suitable for early hospital discharge [2].

A full discussion of the assessment and management of UGIB is available on the RCEM Learning Session Upper Gastrointestinal Haemorrhage.

Learning Bite

Patients with upper gastrointestinal bleeding and haemodynamic instability require urgent resuscitation and endoscopy.

Learning Bite

Patients with upper gastrointestinal bleeding who are haemodynamically stable should be assessed using a risk stratification score.

Perforation

Perforation occurs in 2-10% of patients with PUD [23]. It normally involves the anterior wall of the duodenum (60%) but may also affect the gastric antrum (20%) and lesser curvature (20%). Perforation and the resultant bacterial peritonitis have a mortality rate of 30-50% in older patients [4].

Clinical features:

• Acute-onset, severe abdominal pain which rapidly worsens
• Pain may radiate to the back or either shoulder
• Generalised abdominal tenderness with guarding, rebound tenderness or rigidity with hypoactive bowel sounds
• Tachycardia, hypotension, fever and oliguria

An erect chest x-ray may show free subdiaphragmatic air but can not rule out a perforation. If there is a strong clinical suspicion, further investigation with CT Abdomen is indicated.

Initial Management

• Resuscitation as above
• Broad-spectrum intravenous antibiotics (normally a 3rd generation cephalosporin and metronidazole or tazocin)

Definitive Management

• Surgical intervention traditionally consists of laparotomy, placing an omental patch and washout of peritoneal contents.
• Perforated gastric ulcers are treated with an omental patch, wedge resection of the ulcer, or a partial gastrectomy and re-anastomosis [4].
• Laparoscopic repair is now becoming more common. One meta-analysis showed better outcomes compared to laparotomy [35].

Gastric Outlet Obstruction

PUD accounts for 5-8% of cases. Differentials include pyloric stenosis in paediatric populations, and neoplastic lesions (especially pancreatic malignancies) in older populations.

Clinical features:

• Persistent large-volume vomiting containing undigested food
• Dehydration
• Distended, tympanic abdomen
• There may be a palpable epigastric mass or visible peristalsis
• Weight loss, lethargy, and malaise
• There may be a hypochloraemic, hypokalaemic metabolic alkalosis

Initial Management

• Resuscitation.
• Chest x-ray and abdominal x-ray.
• NG tube insertion and aspiration of gastric contents.

Definitive Management

• Upper GI Endoscopy is performed to assess the site, severity and nature of the disease.
• Surgical removal of the obstructive lesion may be possible.
• Obstruction caused by inflammation and oedema due to PUD usually responds to H. pylori eradication and proton-pump inhibitors (PPIs).

Malignancy

Patients who are > 60 or with alarm features in the history should be discussed with gastroenterology and have inpatient or outpatient endoscopy within 2 weeks.