Table of contents
- 1. Introduction
- 2. Assessment
- 3. Treatment
- 3.1. Before Endoscopy
- 3.2. Endoscopic Therapy
- 3.3. After Endoscopic Therapy
.
Introduction
- Causes:
- H.pylori
- NSAID use
- Esophageal erosions (GERD)
- Mallory Weiss Tears
- etc
Assessment
- Glasgow-Blatchford Score
- >70yo --> 0-1 score --> Outpatient management
- <70yo --> 0-2 score --> Outpatient management
- 1% risk of intervention and 0.5% mortality
- Hb are poor predictor of bleeding
Treatment
Before Endoscopy
- Hb < 70 --> tranfuse based on TRICC trial (less death, rebleeding and adverse events vs. 90)
- Cardiovascular disease --> Tranfuse < 80
- Reasonable to tranfuse bleeding patients before they get low hb
- PPI
- Meta-analysis of 6 RCTs --> PPI at presentation DO NOT reduce death, surgery, or further bleeding.
- LESS high-risk endoscopic findings
- LESS endoscopic therapy
- Guidelines vary substantially:
- High dose IV PPI: (ESGE Guidelines)
- "May be considered" (Am. J. Gastroenterol., International consensus statement Ann.Intern.Med)
- Do not administer (National institute of health and clinical excellence - London)
- Meta-analysis of 6 RCTs --> PPI at presentation DO NOT reduce death, surgery, or further bleeding.
- Erythromycin (250mg IV 30min prior to endoscopy)
- Increases gastric motility, improves visualization
- Meta-analysis of 4 RCTs decreased need for transfusions
- NG Tube
- No clinical benefit, not sufficient to clear clots improve visual.
- Endoscopy
- Do in 24 hrs as long as:
- Hemodynamically stable (resuscitated)
- Hb > 70
- Scoping ASAP (in 2-6hrs reduces costs)
-
High Risk Endoscopic Features
HIGH RISK (risk of serious bleeding) (BOLD = must intervene)
- Active Spurting (60%)
- Visible Vessel (nonbleeding) (35%)
- Oozing hemorrhage (25%)
- Adherent Clot (0-35%) [unclear if should intervene]
LOW RISK
- Flat Pigmented Spots (5.6%)
- Clean-base Ulcer (0.5%)
- Do in 24 hrs as long as:
- IF Re-Bleeding Occurs
- Repeat endoscopy is better than surgery (based on RCTs)
Endoscopic Therapy
- Injection (epinephrine, alcohol)
- Thermal devices (cautery)
- Clips
After Endoscopic Therapy
- High Risk Findings:
- IV PPI (pantoprazole 80mg + 8mg/hr) x72hrs.
- (meta-analysis, this reduces risk of bleeding, need for surgery, mortality)
- Recent meta-anlysis: Intermittent PO or IV PPI = noninferior to IV infusion post-endoscopy.
- Typically 80mg bolus, followed by 40-80mg BID PO or IV
- High Risk Findings + Clinical Factors (hemodynamic instability, old age, major conditions)
- Initially thought bleed risk >3days is low, recommend d/c.
- However new evidence that 44% of high risk re-bleed >3 days post (2-3 weeks).
- Recommend BID PPI for 2 weeks, followed by daily.
- 18% ARR of rebleeding.
- H.pylori
- Treat H.pylori
- Eradication must be confirmed via breath test or stool test, or repeat endoscopy (if another reason to do it).
- Must not receive bismuth or abx x4w before testing, and no PPI x2w. (false negatives).
- H2 receptor antagonists are OK!
- Stop NSAIDS
- Permanently.
- If must use, use with PPI.
- Low Dose ASA
- RCT --> resume at 24hrs and resume at 8 weeks.
- 24 hrs -->
- No increase in rebleeding
- Lower mortality
- High risk of cardiovascular events in 1-2 weeks of discontinuing ASA.
- Recommended restart 1-7 days after bleeding stops.
- Add PPI to ASA after bleed
- 24 hrs -->
- RCT --> resume at 24hrs and resume at 8 weeks.
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