Upper GI Bleeding Revisited 2016

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    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)
    • 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%)
    • 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
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