Acute Upper GI Bleeding - The inpatient consult and Management

Transcription

1 Acute Upper GI Bleeding - The inpatient consult and Management Nimish Vakil MD AGAF FASGE FACG University of Wisconsin School of Medicine and Public Health, Madison WI

2 Consult 1 85 year old otherwise healthy woman who recently had a hip replacement The orthopedic surgeon prescribed meloxicam for pain The patient woke up last night and had a dark black bowel movement Asymptomatic, BP 120/86; pulse=88/min; Hgb=13; BUN 8 The hospitalist does not think she needs she needs to stay in the hospital

3 Assessing the urgency on the telephone Age over 60. Presence of signs of shock at admission. Coagulopathy. Bright red blood in the vomitus Cardiovascular disease

4 Blatchford Score Initial aglasgow- ssessment Her score: 0 Likelihood of needing endoscopic interven6on or transfusion: 0%- very low hip://gihep.com/calculators/bleeding/blatchford- score/ Pang S. Gastrointest. Endosc. 71, (2010)

5 Initial triage: important points Few patients have a score of Blatchford score of 0: Range 1-15%; usual reported: 5% With a score of Blatchford score of 1-2: UK study: Prevalence 20%; 5% needed endoscopic intervention Hong Kong: 15% Score > 8: 50% need intervention Co- morbidity is not a factor with this scale! Use common- sense Pang S. Gastrointest. Endosc , Stanley A.2009 Lancet 373, (2009)

6 Inpatient consult #2 85 year old woman recently had a hip replacement The orthopedic surgeon prescribed meloxicam for pain The patient woke up last night and had a dark black bowel movement and blacked our brie^ly Asymptomatic, BP 98/60; pulse 104/min; Hgb=8; BUN 18; mild dehydration She has a history of coronary artery disease, 4 stents and daily baby aspirin and clopidogrel use

7 Rockall score Rockall Gut 1996;38: 316

8 Rockall scale Rockall Gut 1996;38: 316 hip://gihep.com/calculators/bleeding/rockall- score/

9 Predictive value of the Rockall score Score Mortality % Mortality with re- bleeding % Rockall Gut 1996;38: 316

10 Initial management Correct ^luid losses: two wide- bore lines Decisions on blood transfusion over- transfusion may be as damaging as under- transfusion. Platelet transfusions: no active bleeding and hemodynamically stable : NO Platelet transfusions: actively bleeding and have a platelet count < : YES Consider: Fresh frozen plasma prothrombin time (INR) or a greater than 1.5 times normal or on coumadin

11 The danger of over transfusion of blood Villanueva New Engl J Med 2013;368:11

12 The potential value of an NG aspirate Barkun A. Ann Intern Med. 2003;139(10):

13 Intravenous PPIs: yes or no?

14 Intravenous PPI therapy can change the need for endoscopic therapy Lau New Engl J Med 2007;356:1631

15 Risk of recurrent bleeding Lau New Engl J Med 2007;356:1631

16 Intravenous PPIs in Peptic ulcer bleeding Sung J Ann Intern Med. 2009;150(7):

17 Outcomes in RCT of iv PPIs Parameter Esomeprazole N=375 Placebo N=389 P value Rebleed <72 h 5.9% 10.3% P= Rebleed <7 days P= Re- bleed <30 days 2.7% 5.4% P= All cause mortality 0.8% 2.1% P=0.22 Surgery <30 days 2.7% 5.4% P=0.059 Endoscopic re- treatment 6.4% 11.5% P=0.012 Sung J Ann Intern Med. 2009;150(7):

18 Inappropriate use of PPIs In a US community hospital setting: 56% of patient prescribed intravenous PPIs had no acceptable indication for their use Another US study: 50% of patients receiving PPI therapy had an appropriate indication. Am J Gastroenterol ;99:1233-7; Clin Gastroenterol Hepatol Dec;3(12):

19 International guidelines for GI Bleeding Recommendation 18: In patients awaiting endoscopy, empirical therapy with a high- dose proton pump inhibitor should be considered. Recommendation: C (vote: a, 40%; b, 32%; c, 16%; d, 12%); Evidence: III Taking proton pump inhibitors 24 to 48 hours before endoscopy signi^icantly reduced serious lesions and the need for endoscopy However, overall there was no effect of taking a proton pump inhibitor on further bleeding, need for surgery or risk of death. - Barkun A. Ann Intern Med. 2003;139(10): Sreedharan A Cochrane reviews 2012

20 Our patient Two iv lines were started in the ER A bolus of PPI was administered and a continuous infusion was started in the ER An NG tube was not placed Hgb/Hct repeated in 4 hours showed no appreciable change Vital signs remain stable The patient has endoscopy late that afternoon

21 Endoscopy: Intervention and risk assessment

22 The value of the endoscopic classi^ication:

23 Discontinue aspirin? Sung J Ann Intern Med. 2010;152:1-9.

24 Bleeding to discharge Patients requiring endoscopic therapy have lower re- bleeding rates if iv PPI therapy is a administered for 72 hours Low risk lesions: oral PPI therapy and discharge Recommendation 20: Patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present. Recommendation: A (vote: a, 96%; b, 4%); Evidence: I

25 H pylori eradication vs antisecretory therapy in rebleeding Cochrane Trials database accessed 9/2008

26 H pylori: Important points Rapid urease test and histology may be falsely negative in acute GI bleeding A positive test is reliable Strategy: Initiate treatment for H pylori if RUT is positive Order serology if RUT is negative & treat if positive Test as an outpatient off all PPIs

27 Consult #3 A 50 year old man with cirrhosis die to alcohol and hepatitis C is admitted to the hospital with hematemesis Vital signs: pulse 100/min BP 90/60 He has a ^irm nodular liver, moderate ascites and is awake and alert

28 Initial management Principles remain the same Over transfusion is associated with poorer outcomes Pharmacologic therapy in suspected variceal bleeding Octerotide 50 mcg bolus followed by 50 mcg/h for 2-5 days Somatostatin 250 mcg bolus followed by 250 mcg/h

29 Antibiotic Prophylaxis 7 day treatment with Nor^loxacin 400 mg twice a day for 7 days Intravenous cipro^loxacin 400 mg/day Ceftriaxone 1 gram intravenously/day Endoscopy Within 12 hours with variceal band ligation Post- endoscopy management of varices Garcia- Tsao Hepatology 2007;46:923

30 Conclusions Assess risk early and after endoscopy Don t overtreat with transfusion, platelets, FFP Endoscopy is not a substitute for resuscitation Don t automatically stop aspirin Identify the patient with suspected varices