GI bleeding. David Patch Royal Free Hospital

Transcription

1 GI bleeding David Patch Royal Free Hospital

2 Contents: Context NCEPOD Non variceal bleeding Variceal bleeding Managerial/organisational stuff Not showing whole lot of endoscopic videos

3 Percentage of Deaths % Annual 30-day mortality 30.0 p< / / / / / / / / / /10 Financial Year

4 Percentage 30-day mortality: Monday-Friday vs Weekend 18% 16% 14% 12% 10% 8% 6% 4% 2% p<0.05 0% 2000/ / / / / / / / / /10 Financial year of Discharge Monday and Friday Saturday or Sunday

5 Outcome of hospital episode NCEPOD 2015, review of care of patients who had severe GI haemorrhage Mortality NVUGIB = 21.5% (77/358) LGIB = 20% (18/138) VUGIB = = 32% (16/50) No diagnosis = 29% (21/72) 5

6 Age 6

7 Age 7

8 Endoscopy 24/7 8

9 Endoscopy service responsibility 9

10 Team managing upper GI patient on admission 10

11 Proctoscopy, sigmoidoscopy & colonoscopy 11

12 Shock Index (pulse/systolic BP) and time to OGD 12% (73/610) shock/syncope Haemodynamics at presentation 26% (152/587) SI >1 OGD < 24 hours 79% (74/94) SI >1 62% (139/225) SI <1 12

13 Shock Index and time to OGD NICE QS - in those with haemodynamic instability OGD < 2 hours of optimal resuscitation 8.5% (8/94) SI >1 had OGD < 2 hours < 4 hours 22% (21/94) < 4 hours with SI >1 13

14 Overall quality of care New admissions Shock index <1 no difference IH vs. OOH Shock Index >1 59% (16/27) good care presented 8am-6pm weekdays 36% (13/36) remainder 14

15 Case study 15

16 Formal network for embolisation 16

17 NCEPOD conclusions Major bleed should be admitted to hospital with 24/7 access to endoscopy/ir etc Those that do not have 24/7 services should develop FORMAL networks Upper AND lower GI bleeding should be managed by single team Major bleeds discuss with responsible consultant within 1 hour On going management of major GI bleeding managed by said consultant All patients with major GI bleed should have documented rebleed plan

18 Medical management of non variceal upper GI bleed NBM Score Decent access Cross match But don t rush to give IV PPI Refer for endoscopy (timings)

19 Recommendation 1: Risk stratify patient presenting with Upper GI Bleeding Glasgow Blatchford score Full Rockall score post endoscopy (Baylor Score)

20 Glasgow Blatchford Score (GBS): to predict need for intervention or death Lancet 2000 & 2009 Identifying those at low risk (GBS=0): urea < 6.5 mmol/l Hb > 130 g/l men > 120 g/l women systolic BP >110mmHg pulse < 100/min No melaena, syncope, CCF, liver disease

21 Sensitivity GBS vs admission vs full Rockall scores: APT 2011;34: Endoscopy or surgery Specificity GBS Full Rockall Adm Rockall ref

22 Avoid admission in low risk patients? Safe to avoid admission in low risk patients (GBS=0) GBS=0 has 100% sensitivity for intervention/death Accounts for 5-22% all presentations Some studies suggest can extend GBS low risk definition (+/- age component) Superior to admission-rockall in identifying risk Gralenk, Gastrointest Endosc 2004;60:9-14 Chen, Am J Emerg Med. 2007(25); Romagnuola, Arch Intern Med 2007;167: Masaoka, J Gastro Hepatol 2007;22: Stanley, Lancet 2009;373:42-47 Pang, GI Endosc 2010:71: Chan, Front Gastroenterol 2011;2:19-25

23 Stigmata of Bleeding Risks of Re-bleeding and Prevalence Clean base 49% bleeder 7% NBVV 8% dot 23% clot 13% 0 Active bleeder NBVV Clot Dot Clean base

24 Who and how to treat? 80% stop bleeding spontaneously

25 Eradicate HP! Non NSAID ulcers Sung JY et al 1997 DDS Aspirin ulcers Chan et al NEJM NSAID ulcers Chan et al NEJM

26 Post Ulcer Bleeding: NSAID? Stop Aspirin users? Restart post hemostasis

27 endoscopy Dual therapy Clip is good for radiologist

28 Original Article Transfusion Strategies for Acute Upper Gastrointestinal Bleeding Càndid Villanueva, M.D., Alan Colomo, M.D., Alba Bosch, M.D., Mar Concepción, M.D., Virginia Hernandez-Gea, M.D., Carles Aracil, M.D., Isabel Graupera, M.D., María Poca, M.D., Cristina Alvarez-Urturi, M.D., Jordi Gordillo, M.D., Carlos Guarner-Argente, M.D., Miquel Santaló, M.D., Eduardo Muñiz, M.D., and Carlos Guarner, M.D. N Engl J Med Volume 368(1):11-21 January 3, 2013

29 Rate of Survival, According to Subgroup. Villanueva C et al. N Engl J Med 2013;368:11-21

30 pragmatics Transfuse sparingly Don t let 80 year old leave hospital with HB of 7 Oral/IV iron

31 Variceal bleeding Younger Sicker?more frightening There are some tricks

32 resuscitate ABC Saline followed by blood:ffp Antibiotics Terlipressin (but fill first) AIRWAY/AIRWAY/AIRWAY (tricks) ER Crash bell blood

33 EARLY REBLEEDING in RANDOMIZED TRIALS of PROPHYLACTIC vs. ON DEMAND ANTIBIOTICS Frequency of bleeding 7 days 6 weeks

34 ACUTE VARICEAL BLEEDING PROPHYLACTIC ANTIBIOTICS AND MORTALITY

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42 Take home Still stress about them Very rare to exsanguinate Co-morbidities and aspiration profoundly effect outcome Challenge the powers that be (including colleagues) if there is not adequate provisionput it on your trusts risk register