On-Call Upper GI Bleeding. Upper Gastrointestinal Bleeding

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1 On-Call Upper GI Bleeding John R Saltzman MD, FACG Director of Endoscopy Brigham and Women s Hospital Associate Professor of Medicine Harvard Medical School Upper Gastrointestinal Bleeding 300, hospitalizations/year ations/ in USA 50% additional episodes of GI bleeding during hospitalizations for other reasons Hospital charges of $7.4 Billion/year in USA 2-14% mortality rate Abougergi M, Saltzman JR. ACG Annual Meeting 2012 October

2 Objectives Prognostic indicators and scores Role of medications Timing of endoscopy examination Endoscopic methods to treat t bleeding Initial Assessment and Risk Stratification Assess hemodynamic status immediately Insert 2 large bore IV s and begin resuscitation Blood transfusions Target hemoglobin > 7 g/dl (> 10 g/dl if intravascular volume depletion or CAD) Target INR < 2.5 Risk stratification into higher and lower categories Patient triage Timing of endoscopy Laine L, Jensen D. Am J Gastroenterol 2012;107:345 October

3 Impact of Anticoagulation and Therapeutic Endoscopy 233 patients post successful therapeutic endoscopy 44% patients had an INR >1.3 (95% < 2.7) Rebleeding Rate 23% in anticoagulated patients (INR >1.3) 21% in patients with normal coagulation (INR s <1.3) INR not a predictor of rebleeding, length of stay, transfusions, surgery, or mortality Endoscopic therapy is appropriate in mildly to moderately anticoagulated patients Wolf AT. Am J Gastroenterol 2007;102:290 INR and Upper GI Bleeding RUGBE database cohort of 1869 patients Elevated INR in 462 patients (25%) INR >2.5 in 142 patients (8%) Results INR did not predict rebleeding INR >1.5 predicted increased mortality (OR=1.96) Shingina A. Aliment Pharmacol 2011;33:1010 October

4 Initial Assessment and Risk Stratification Recommendations Early risk stratification, by using validated prognostic scales International Consensus Guidelines Risk assessment should be performed to stratify patients into higher and lower risk categories ACG 2012 Practice Guidelines Barkun A. Ann Intern Med 2010;152:101; Laine L, Jensen D. Am J Gastroenterol 2012;107:345 Rockall Risk Score (Gut 1996;38:316-21) Assesses mortality Incorporates clinical and endoscopic data Glasgow Blatchford Risk Score (Lancet 2000;356: ) Assesses need for intervention Incorporates only information available at presentation October

5 AIMS65 Score 1. Albumin <3.0 mg / dl 2. INR > Mental status change 4. Systolic blood pressure <90 5. Age >65 years Saltzman JR. Gastrointest Endosc 2011;74(6): Mortality Correlates with AIMS65 Score ) Mortality (%) Number of Risk Factors Present October

6 Rebleeding: AIMS65 vs. GBRS Hyett B. ACG Annual Meeting 2011 Is there a role for NG lavage? Retrospective study of patients with upper GI bleeding receiving NG lavage (193 pts) or no NG lavage (193 pts) Results: Patients with NGL associated with earlier times to endoscopy (hazard ratio 1.49) Bloody NG aspirate associated with high risk lesions NGL lavage did not affect main study outcomes of mortality, LOS, surgery or transfusions Conclusion: NG lavage should not be routinely performed in patients with upper GI bleeding Huang ES. Gastrointest Endosc 2011;74(5): Pallin DJ, Saltzman JR. (editorial) Gastrointest Endosc 2011;74(5):981-4 October

7 The Role of NG Tube Lavage NG or orogastric lavage is not required in patients with upper GI bleeding for diagnosis, prognosis, visualization, or therapeutic effect ACG 2012 Practice Guidelines Laine L, Jensen D. Am J Gastroenterol 2012;107: Medical Therapy: Upper GI Bleeding Antacids H 2 -receptor antagonists Proton pump inhibitors Octreotide October

8 Should Omeprazole be Started Before Endoscopy? Upper GI Bleeding Omeprazole 80/8 mg IV Placebo Infusion Endoscopy Lau JY. N Engl J Med 2007;356:1631 Omeprazole before Endoscopy Percent Patients * * Lau JY. N Engl J Med 2007;356:1631 October

9 Numbers of Ulcers Found during the First Endoscopic Examination Lau JY. N Engl J Med 2007;356: Role of Erythromycin Before Endoscopy in UGI Bleeding IV erythromycin motilin-like prokinetic Erythromycin 3 mg/kg or 250 mg IV over 30 minutes 1-hour before EGD Quality of gastric exam significantly better Decreased need for a repeat upper endoscopy No difference in: Length of hospital stay Need for surgery Adverse events Barkun AN. Gastrointest Endosc 2010;72:1138 October

10 Role of Erythromycin in UGIB Intravenous infusion of erythromycin y (250 mg ~30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for repeat endoscopy ACG 2012 Practice Guidelines Laine L, Jensen D. Am J Gastroenterol 2012;107: Variceal Bleeding and Antibiotics Bacterial infections present in up to 20% of cirrhotics with GI bleeding Up to an additional 50% develop infections when hospitalized Prophylactic antibiotics Reduce infections (45% vs. 14%) Reduce rebleeding (78% vs. 33% at 7 days) Reduce mortality (24% vs. 15%) Most trials use a daily oral quinolone Bernard B. Hepatology 1999;29:1655; Hou MC. Hepatology 2004;39:746 October

11 Medical Therapy Summary Proton pump inhibitors (80 mg IV bolus followed by 8 mg/hour IV infusion x 72 hrs) are effective in patients with high risk stigmata and along with endoscopic therapy Therapy with erythromycin should be selectively considered before endoscopy Give antibiotics for possible variceal bleeding Octreotide (terlipressin outside USA) should be given to patients with variceal bleeding Timing of Endoscopy Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper GI bleeding International Consensus Guidelines. Barkun A. Ann Intern Med 2010;152:101 Patients with UGI bleeding should generally undergo endoscopy within 24 hours of admission, following resuscitative efforts to optimize hemodynamic parameters ACG 2012 Practice Guidelines. Laine L, Jensen D. Am J Gastroenterol 2012;107:345 October

12 Emergent or Urgent Endoscopy? Emergent (<6-8 hours) endoscopy (EE) vs. urgent (8-24 hours) endoscopy (UE) Retrospective series (n=860) More endoscopic therapy in EE group No differences in: Rebleeding rate Length of stay, transfusions, surgery & mortality Tai CM. Am J Emerg Med 2007;25:273 Targownik LE. Can J Gastroenterol 2007;21:425 Sarin N. Can J Gastroenterol 2009;23:489 Urgent Endoscopy (< 12 hours) Always after hemodynamic resuscitation and stabilization Hemodynamically unstable initially Hematemesis Suspected active bleeding Suspected variceal bleeding Laine L, Jensen D. Am J Gastroenterol 2012;107:345; Tsoi KKF. Nat Rev Gastroenterol Hepatol 2009; 6: October

13 Endoscopic Predictors Stigmata of Recent Hemorrhage Endoscopic Predictors Stigmata of Recent Hemorrhage Percent Mallory Weiss Tear Further Bleeding Ulcer (Clean Base) Ulcer (Flat Spot) Ulcer (Clot) Ulcer (Visible Vessel) Active Bleeding Indications for Endoscopic Therapy Stigmata Endoscopic Therapy? Active Bleeding Yes Non-Bleeding Visible Vessel Yes Adherent Clot +/- Flat Spot No Clean Ulcer Base No Laine L, Jensen D. Am J Gastroenterol 2012;107: October

14 Endoscopic Therapeutic Options Injection Thermal (contact) Heater probe Bipolar probe Monopolar Thermal (non-contact) Argon plasma coagulation Mechanical Hemoclips Banding Combination Combination Therapy Inject first with dilute epinephrine Combine with thermo-coagulation therapy May also combine injection with hemoclips Combination therapy is safe and effective Barkun A. Ann Intern Med 2003;139:843 October

15 Combination Therapy vs. Hemoclips Study Prospective randomized controlled trial of acute non-variceal upper GI bleeding All pts on high dose proton pump inhibitors Primary Control Rebleeding Rate % % P=0.45 Hemoclips Combination P=0.49 Hemoclips Combination Saltzman JR. Am J Gastroenterol 2005;100:1503 Hemoclips for Upper GI Bleed Meta-analysis of 15 RCT s of 1156 patients 390 clips alone 242 clips and injection 359 injection alone 165 thermocoagulation with or without injection Hemoclips superior to injection therapy alone Definitive hemostasis 87% vs. 75% Hemoclips comparable to thermal coagulation Definitive hemostasis 82% vs. 81% Sung JJ. Gut 2007;56:1364 October

16 On-Call Upper GI Bleeding: Summary Perform initial resuscitation Incorporate GI bleeding risk scores Provide adequate medical therapy Perform endoscopy in a timely manner Use effective endoscopic treatments (hemoclips and combination therapies) October

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