James Irwin Gastroenterology Department Palmerston North Hospital. Acute Medicine Meeting Hutt Hospital. June 21, 2015

Transcription

1 The Management of Acute Upper Gastrointestinal Bleeding James Irwin Gastroenterology Department Palmerston North Hospital Acute Medicine Meeting Hutt Hospital June 21, 2015

2 Outline Common Definitions and Risk Scores in Upper Gastrointestinal Bleeding Epidemiology Basic Management Decision points Long term mangagment Slide 2 of 33

3 Common Definitions and Risk Scores in Upper Gastrointestinal Bleeding Upper GI bleeding is defined as: Bleeding proximal to ligament of Trietz Forrest Classification 1 of peptic ulceration Rockall Score 2 Blatchford Score 3 1 Forrest, Finlayson, and Shearman Rockall et al O. Blatchford, Murray, and M. Blatchford Slide 3 of 33

4 Forrest classification 4 Grading of acuity of peptic ulceration 1a Spurting bleeding 1b Oozing bleeding 2a Visible vessel 2b Adherent clot 2c Red spot 3 Clean base 4 Forrest, Finlayson, and Shearman Slide 4 of 33

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7 Rockall Score 5 Pre-endoscopy and post-endoscopy score Designed to predict mortality Age <60 Years Years 80 Shock BP 100,pulse<100 Pulse 100 BP<100 Comorbidity No major Heart failure, Renal/liver failure comorbidity IHD, any major Disseminated comorbidity malignancy Diagnosis Mallory Weis, All other Malignancy No lesion seen, diagnoses No SRH Major SRH None or Blood in lumen, dark spot visible or spurting vessel, adherent clot Table: Rockall score. SRH = stigmata of recent haemorrhage 5 Rockall et al Slide 7 of 33

8 Blatchford score 6 Designed to predict combined endpoint of death, surgery, blood transfusion, performance of endoscopic therapy at endoscopy Blood Urea mmol/l Hb (g/l, men) <10 Hb (g/l, women) <10 Systolic BP mmhg <90 Pulse (per min) >100 Clinical Melaena Syncope Comorbidity Hepatic disease Cardiac failure Table: Blatchford score. 6 O. Blatchford, Murray, and M. Blatchford Slide 8 of 33

9 Epidemiology Age Standardized Incidence between 40 and 200 per 100,000 per year 7 30 day mortality 5-10% 8 Associated with H. pylori infection 9 NSAID use 10 Anticoagulant use 11 Increasing age 12 Male sex 13 Maori ethnicity 14 7 Lewis et al. 2002; O. Blatchford, Davidson, et al. 1997; Loperfido et al. 2009; Rockall et al. 1995; Irwin et al. 2014b. 8 O. Blatchford, Davidson, et al. 1997; Loperfido et al. 2009; Irwin et al. 2014b. 9 Schöttker et al García Rodríguez L Hallas et al O. Blatchford, Davidson, et al O. Blatchford, Davidson, et al. 1997; Rockall et al Irwin et al. 2014b. Slide 9 of 33

10 Findings at Endoscopy Gastric Ulcer 19 Duodenal Ulcer 21 Gastric Cancer 2.5 Oesophogeal Cancer 0.9 Gastric Erosions 14 Duodenal Erosions 8.4 Vascular Lesion 3.1 Oesophogeal Varices 5.1 Oesophagitis 15 Mallory Weiss Tear 4.05 Normal Endoscopy 15 Slide 10 of 33

11 Basic Management Algorithm Safe IV access - 2 large bore lines Crossmatch Resuscitation Monitor and maintain end organ perfusion blood pressure, urine output, level of consciousness Correct coagulation defects PPI Endoscopy Address risk factors H. pylori status NSAID use Antiplatelet and anticoagulant therapy Home! Slide 11 of 33

12 Decision Points When to transfuse? PPI therapy Continue or stop antiplatelet therapy? Continue or stop anticoagulant therapy? Timing of endoscopy? What endoscopic therapy? Discharge criteria? What is a rebleeding episode? Slide 12 of 33

13 When to transfuse? Evidence of massive bleeding Haemodynamic instability Haemodynamically stable anaemia? Evidence in trauma and in variceal bleeding of survival benefit from lower transfusion targets 15 No clear data in undifferentiated GI bleed 16 Hb<70 g/l 15 Hébert et al. 1999; Villanueva et al Villanueva et al Slide 13 of 33

14 Sub-group analysis Villanueva et al

15 PPI therapy No reduction in mortality Reduction in rebleeding rates Before or after endoscopy? First large randomised placebo controlled trial demonstrated no benefit of IV PPI before endoscopy 18 Hong Kong study demonstrated IV PPI after endoscopy reduces rebleeding (not mortality) 19 IV or oral dosing? There is evidence for oral dosing 20 Dose needs to be large enough: 40mg bd omeprazole 18 Daneshmend et al Lau et al Kaviani et al. 2003; Javid et al Slide 15 of 33

16 Antiplatelet therapy Aspirin, clopidogrel Usually given for atherosclerotic disease Irreversible inhibition of COX or ADP receptors Effect lasts until new platelets are formed in absence of drug (3-7 days) For continuation of aspirin: Reduced cardiovascular mortality 21 Increased risk of rebleeding 21 Sung et al Slide 16 of 33

17 Survival analysis Sung et al

18 Anticoagulant therapy Anticoagulation for AF, prosthetic heart valve, venous thromboemboism Cohort with high comorbidity, however lower rates of 30 day mortality 23 No randomized controlled data regarding how to manage anticoagulation Status quo is to reverse warfarin anticoagulation acutely with vitamin K/FFP/prothrombinex Should warfarin be restarted? Restarting warfarin associated with reduction in thromboembolic stroke, no increase in recurrent bleed at 90 days 24 For patients with AF reduced mortality over subsequent 2 years associated with restarting warfarin Irwin et al. 2014a. 24 Sengupta et al Qureshi et al Slide 18 of 33

19 Timing of endoscopy For endoscopic therapy to provide benefit, bleeding must be identified and successfully treated. The earlier, the better? Resource constraint for after hours procedures Within 24 hours 26 Reduction in rebleeding, length of stay Negative studies for early endoscopy (within 6 hours) 27 DDW presentions 2015 Higher mortality with early endoscopy (<6 hours) Observational studies, likely selection bias Hypothesis that early endoscopy is detremental - effect of procedural sedation? - aspiration? - inadequate resuscutation? Riccardo Marmo, Stig Laursen 26 Cooper et al. 1999; Hwang et al Tsoi, Ma, and Sung 2009; Schacher et al. 2005; Sarin, Monga, and Adams 2009; Lin, Wang, et al Slide 19 of 33

20 Timing of endoscopy Can stratify patients and select who are likely to benefit from early endoscopy Rockall score 28 Predicts death Blatchford score 29 Predicts need for: requirement of blood transfusion, requirement of endoscopic or operative intervention to control bleeding, death, rebleeding, or a substantial fall in haemoglobin Waikato analysis 30 Association of presenting features with endoscopic lesions that were treated. Presentation with fresh haematemesis, fresh melaena, high urea, low BP, male sex, history of peptic ulcer disease. 28 Rockall et al O. Blatchford, Murray, and M. Blatchford Irwin et al Slide 20 of 33

21 What endoscopic therapy? For peptic ulceration Adrenaline injection 31 Dual therapy Heater probe 32 Clip placement For oesophogeal varices sclerotherapy 33 banding Cook et al Chung et al. 1997; Lin, Tseng, et al Infante-Rivard, Esnaola, and Villeneuve Stiegmann et al Slide 21 of 33

22 Who is safe to discharge before or after endoscopy? Before endoscopy Blatchford score = 0 35 After endoscopy post-endoscopy Rockall score O. Blatchford, Murray, and M. Blatchford 2000; Stanley et al Rockall et al. 1996; Dulai et al Slide 22 of 33

23 Rebleeding episode? Rebleed associated with increased risk of death 37 What is a rebleed? Fresh haematemesis or Combination of Ongoing melaena and/or Further drop in Hb and/or Haemodynamic instability Management Resuscitation Endoscopy/surgery/...interventional radiology 37 Rockall et al Slide 23 of 33

24 Non-acute decisions Test and treat for H. pylori if peptic ulcer disease Cease NSAID Decide ongoing anticoagulation Usually restart warfarin after 1-14 days Decide ongoing antiplatelet therapy If gastric ulcer, requires repeat endoscopy to ensure ulcer healing 38 Decide long term PPI Hansson et al Laine and Jensen Slide 24 of 33

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26 Bibliography I Blatchford, O., L. A. Davidson, et al. (Aug. 30, 1997). Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. BMJ (Clinical research ed.) , pp Blatchford, O., W. R. Murray, and M. Blatchford (Oct. 14, 2000). A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet , pp Chung, S. S. et al. (May 3, 1997). Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers. BMJ (Clinical research ed.) , pp Cook, D. J. et al. (Jan. 1992). Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 102.1, pp Cooper, G. S. et al. (Feb. 1999). Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointestinal endoscopy 49.2, pp Daneshmend, T. K. et al. (Jan. 18, 1992). Omeprazole versus placebo for acute upper gastrointestinal bleeding: randomised double blind controlled trial. BMJ , pp Slide 26 of 33

27 Bibliography II Dulai, G. S. et al. (Mar. 2002). Utilization of health care resources for low-risk patients with acute, nonvariceal upper GI hemorrhage: an historical cohort study. Gastrointestinal Endoscopy 55.3, pp Forrest, J. A., N. D. Finlayson, and D. J. Shearman (Aug. 17, 1974). Endoscopy in gastrointestinal bleeding. Lancet , pp García Rodríguez L, C. C. (Jan. 12, 1998). RIsk of hospitalization for upper gastrointestinal tract bleeding associated with ketorolac, other nonsteroidal anti-inflammatory drugs, calcium antagonists, and other antihypertensive drugs. Archives of Internal Medicine 158.1, pp Hallas, J. et al. (Oct. 7, 2006). Use of single and combined antithrombotic therapy and risk of serious upper gastrointestinal bleeding: population based case-control study. BMJ , pp. 726 Hansson, L.-E. et al. (July 25, 1996). The Risk of Stomach Cancer in Patients with Gastric or Duodenal Ulcer Disease. New England Journal of Medicine 335.4, pp Hébert, P. C. et al. (Feb. 11, 1999). A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care. New England Journal of Medicine 340.6, pp Hwang, J. H. et al. (June 2012). The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointestinal endoscopy 75.6, pp

28 Bibliography III Infante-Rivard, C., S. Esnaola, and J. P. Villeneuve (Apr. 1989). Role of endoscopic variceal sclerotherapy in the long-term management of variceal bleeding: a meta-analysis. Gastroenterology 96.4, pp Irwin, J. et al. (July 18, 2013). Factors at presentation predictive of a requirement for endoscopic therapy in patients presenting with overt upper gastrointestinal haemorrhage: a retrospective observational study. Frontline Gastroenterology, (July 10, 2014a). Supratherapeutic anticoagulation at presentation is associated with reduced mortality in nonvariceal upper gastrointestinal hemorrhage. Endoscopy International Open 2.3, E148 E152 Irwin, J. et al. (Aug. 2014b). Incidence of upper gastrointestinal haemorrhage in Maori and New Zealand European ethnic groups, Internal Medicine Journal 44.8, pp Javid, G. et al. (Sept. 2001). Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer. The American Journal of Medicine 111.4, pp Kaviani, M. J. et al. (Jan. 1, 2003). Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical trial. Alimentary Pharmacology & Therapeutics 17.2, pp Laine, L. and D. M. Jensen (Mar. 2012). Management of Patients With Ulcer Bleeding. The American Journal of Gastroenterology 107.3, pp

29 Bibliography IV Lau, J. Y. et al. (Aug. 3, 2000). Effect of Intravenous Omeprazole on Recurrent Bleeding after Endoscopic Treatment of Bleeding Peptic Ulcers. New England Journal of Medicine 343.5, pp Lewis, J. D. et al. (Oct. 2002). Hospitalization and mortality rates from peptic ulcer disease and GI bleeding in the 1990s: relationship to sales of nonsteroidal anti-inflammatory drugs and acid suppression medications. The American journal of gastroenterology 97.10, pp Lin, H. J., G. Y. Tseng, et al. (May 1999). Comparison of adrenaline injection and bipolar electrocoagulation for the arrest of peptic ulcer bleeding. Gut 44.5, pp Lin, H. J., K. Wang, et al. (June 1996). Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study. Journal of clinical gastroenterology 22.4, pp Loperfido, S. et al. (Aug. 2009). Changing trends in acute upper-gi bleeding: a population-based study. Gastrointestinal endoscopy 70.2, pp Qureshi, W. et al. (Feb. 15, 2014). Restarting Anticoagulation and Outcomes After Major Gastrointestinal Bleeding in Atrial Fibrillation. American Journal of Cardiology 113.4, pp

30 Bibliography V Rockall, T. A. et al. (July 22, 1995). Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ : British Medical Journal , pp Rockall, T. A. et al. (Mar. 1996). Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38.3, pp Sarin, N., N. Monga, and P. C. Adams (July 2009). Time to endoscopy and outcomes in upper gastrointestinal bleeding. Canadian Journal of Gastroenterology = Journal Canadien De Gastroenterologie 23.7, pp Schacher, G. M. et al. (Apr. 2005). Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study. Endoscopy 37.4, pp Schöttker, B. et al. (May 2012). Helicobacter pylori Infection Is Strongly Associated With Gastric and Duodenal Ulcers in a Large Prospective Study. Clinical Gastroenterology and Hepatology 10.5, e1 Sengupta, N. et al. (Feb. 2015). The Risks of Thromboembolism Vs. Recurrent Gastrointestinal Bleeding after Interruption of Systemic Anticoagulation in Hospitalized Inpatients With Gastrointestinal Bleeding: A Prospective Study. The American Journal of Gastroenterology 110.2, pp

31 Bibliography VI Stanley, A. et al. (Jan. 2009). Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. The Lancet , pp Stiegmann, G. V. et al. (June 4, 1992). Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. The New England journal of medicine , pp Sung, J. J. Y. et al. (Jan. 5, 2010). Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Annals of internal medicine 152.1, pp. 1 9 Tsoi, K. K. F., T. K. W. Ma, and J. J. Y. Sung (Aug. 2009). Endoscopy for upper gastrointestinal bleeding: how urgent is it? Nature reviews. Gastroenterology & hepatology 6.8, pp Villanueva, C. et al. (Jan. 3, 2013). Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. New England Journal of Medicine 368.1, pp

32 Incidence per 100,000 per year >80 Age (years)

33 Incidence per 100,000 per year Ethnicity Maori ( n = 268 ) NZ European ( n = 999 ) >80 Age (years)

34 Incidence per 100,000 per year Sex Male ( n = 804 ) Female ( n = 556 ) >80 Age (years)