Acute Gastrointestinal Haemorrhage. Dr Reena Sidhu Consultant Gastroenterologist Hon Sen Lecturer University of Sheffield

Transcription

1 Acute Gastrointestinal Haemorrhage Dr Reena Sidhu Consultant Gastroenterologist Hon Sen Lecturer University of Sheffield

2 Scope of Talk Introduction Upper GI haemorrhage-non variceal - Pathology/ risk stratification/management Lower GI bleeding Obscure GI bleeding ( small bowel ) Summary

3 What was the 30-day mortality for upper gastrointestinal haemorrhage (UGIH) in the UK? 10% 14% 5% 18%

4 Upper GI Bleeding-Background Upper GI bleeding- major cause of hospitalization cases/year= 1 bleed every 6 minutes in the UK mortality between 3-14% Mortality: National UGI Bleed Audit % (N= hospitals) % (N= hospitals) Inpatient UGI bleeding mortality 26%! Management depending on risk stratification Scoring systems derived as a tool to decide on management. Cassana Rev Esp Enferm Dig 2015 Sidhu Eur J Gastro Hep 2009 Hearnshaw Gut 2011, Rockall BMJ 1995

5 Causes of UGI Bleeding Endoscopic Finding Frequency % Oesophagitis 24 Peptic ulcer 20 No diagnosis found 19 Varices/PHG 16.5 Erosive duodenitis or gastritis 9.5 Mallory-Weiss tear 4.3 Malignancy 3.7 Vascular Malformations 2.7 PHG-portal hypertensive gastropathy Hearnshaw SA et el Gut 2011

6 Case 1 Mrs M 79 year old Malaena for 48 hours Hx IHD on aspirin, CCF, AF on warfarin Bp 90/60, Pulse 110bts/min Hb 87, MCV 90, urea 11, creatinine 72 INR 2.9 Risk Stratification: What is her Rockall Score A2 B3 C4 D5 E6 VOTE NOW

7 Basic Assessment: Rockall Scoring Variable Score 0 Score 1 Score 2 Score 3 Age (years) < >80 Shock None Pulse >100 normal BP Pulse >100 BP <100 Comorbidity None Cardiac; GI cancer; major comorbidity Endoscopy diagnosis Stigmata of bleeding Mallory-Weiss no lesion; no blood None or dark spots All other diagnoses Malignancy of upper GI tract Blood, adherent clot visible vessel Renal failure; liver failure; Disseminated malignancy Initial Score Final Score

8 Prediction of Mortality Final Score Rockall Score Number % Re-bleed % Mortality Rockall TA, et al. Gut 1996;38(3):

9 Blatchford score The Blatchford Score has demonstrated a sensitivity of 99% for identifying high risk patients. Good correlation between Rockall and GBSS which allow stratification of patients into low and high risk groups Blatchford Lancet 2000 De Groot Endoscopy 2012

10 Comparison of Rockall & Blatchford Score Stanley AJ et al ( APT 2011) pts (UK): GBS similar to both Rockall s in predicting death. GBS superior to admission and full Rockall in predicting need for transfusion. GBS similar to full Rockall in predicting need for endo-surgical intervention Aquarius (EJGH 2015)- 520 pts Netherlands- GBS superior to both Rockalls in need to predict treatment ( Endo-surgical & transfusion) Cheng ( APT 2012)- 199 pts: mod GBS and GBS outperformed both Rockall scores in predicting need for intervention but similar to full Rockall in predicting re-bleeding & death. Bryan GIE GBS similar to Full Rockall in predicting endoscopic tx, rebleeding, death but GBS superior in predicting Transfusion & surgery

11 When to Discharge? Isolated (non hospital witnessed haematemesis) Rockall 0 (<60) Blatchford Scoring Requires No Malaena Normal Hb Normal Urea Absence of Syncope Patients may have a low risk of re-bleeding ulcer but age and comorbidity determine risk of dying. Lancet 1996;347: Blatchford O et al Lancet 2000;356: , JA Forrest et al Lancet 1974;ii:394-7 Saeed ZA et al Am J Gastroenterol 1993;88:1842-9

12 Mrs M 79 year old Malaena for 49 hours Hx IHD, CCF, AF Bp 90/60, Pulse 110bts/min Hb 87, MCV 90, urea 11, creatinine 72 Resuscitated with fluids Case 1 Mrs M-Should she be Transfused? A Yes B No

13 To Transfuse or not to Transfuse!? N=4441 Early Transfusion : 2 fold in mortality > 8g/dl <8 g/dl in rebleeding & 24% rebleeding 6.7% rebleeding 23% rebleeding 15% rebleeding 11% mortality 4.3% mortality 13% mortality 13% mortality

14 PPI pre endoscopy? YES / NO Randomised double blind :IV PPI 80mg/ infusion vs placebo N=638 Fewer patients in PPI group had actively bleeding ulcers P=0.01 More patients with clean ulcer bases P=0.001 More patients were discharged within 3 days P=0.005 No differences in death, rebleeding, transfusion requirements or emergency surgery Lau JY et al NEJM 2007;356: Retrospective Canadian review of 385 patients Patients receiving IV PPI therapy were less likely to have rebleeding, surgery, in-hospital mortality or re-admission within 30 days with bleeding 13% versus 25% P=0.005 Keyvani L et al Aliment Pharmacol Ther 2006;24: NICE does not recommend PPI pre endoscopy

15 When should Mrs M be Offered Endoscopy A Within 24 hours B Within 12 hours Please Vote Now

16 Timing of Endoscopy Endoscopy within 12 hours- for patients with high risk clinical features haemodynamic instability despite volume resuscitation and ongoing Gi bleeding. Endoscopy within 24 hours ensure patient is adequately resuscitated Systematic review- Endoscopy within 12 hours : variable results: may reduce transfusion requirement. does not necessarily result in better outcome (mortality/ surgical need). Weekend effect - particularly if emergency endoscopy not available. Sung et al GUT 2011, Tsoi et al Nat Rev Gastroenterol Hepatol 2009

17 PPI or not PPI? ph to 6 IV proton pump IV Bolus of 80 mg followed by an infusion of 8mg per hour for 72 hours (n=240) Thereafter 20mg omeprazole for 8/52 30 day bleeding in 8 patients with PPI (6.7%) versus 27 (22.5%) in the placebo group, p<0.001 (predominantly in the first 3 days) 5 patients died in PPI group (4.2%) versus 12 (10%) in the placebo group, p=0.13 Lau JY et al NEJM 2000;310:310-6 IV PPI infusion reduces re-bleeding need for transfusion need for surgery 24 RCT- Mortality also reduced Sung et al Gut 2011

18 Causes of Peptic Ulcer Disease Helicobacter Pylori H. Pylori peptic ulcer associated with 70% gastric and 90% duodenal ulcers NSAID s Stop NSAID s IF NSAIDs required consider NSAID & PPI / COX 2 selective NSAID &PPI. Holster et al World J Gastroenterol 2012

19 Mrs M- What to do with her Aspirin? A: stop indefinitely B stop temporarily, resume in 3 months C stop temporarily resume in 14 days D stop temporarily resume in 3-5 days E stop and gastro to decide! Please vote now

20 Anti-Platelet therapy in patients with High cardio-thrombotic risk & GI Bleeding When aspirin is used as secondary prophylaxis- Stopping anti-platelet therapy in these patients is associated with high CVS events and mortality but lower re-bleeding! No data on safe period of discontinuation-recommended restarting aspirin Day3-5 provided patient stable Similar for clopidogrel In patients with coronory stents on dual antiplatelet therapy- treatment needs to be individualised: factors :duration of stent<30 days higher risk of thrombosis vs stent>30 days, type of stent (drug eluting/bare metal)-role of continuing aspirin low dose & close liason with cardiology on timing of resuming second antiplatelet agent! Derogar et al Clin Gastro Hep 2013, Ceo Soriano et al Thromb Haemost 2013, Gralnek et al ESGE Guidelines Endoscopy 2015

21 Warfarin/ DOAC Stopping warfarin In patients with a haemodynamic instability- reverse anticoagulation (liase with haematology) INR <2.5 before endoscopy Direct oral anticoagulants (DOACs)- -significant risk of GI bleeding equivalent / greater to warfarin -half life :12 hours in pts with creat clearance >50mls/min If last dose >24hrs-unlikley to be major contribution to bleeding Dabigatran- cleared renally predominantly so half life prolonged in renal impairment. Specific reversal agents ( Idarucizumab (Praxbind)-humanized monoclonal Ab binds to dabigatran-approved by NICE andexanet alfa under development Ruff CT et al Lancet 2014, Kahn et al AJG July 2016 Gralnek et al ESGE Guidelines Endoscopy 2015

22 When would you resume Mrs M anticoagulation? A after 24 hours B after 48 hours C ask a friendly cardiologist! D after 72 hours E depending on endoscopy findings Please Vote now

23 In cases of low risk of re-bleeding- anticoagulation can be restarted after bleeding has stopped > 24 hours In high risk cases : chronic AF with embolic events, prosthetic valves within 3 months/ recent PE- bridging therapy recommended with liason with haematology. Witt DM et al Arch Intern Med 2012, Qureshi W et al Am J Cardiol 2014 Gralnek Gut 2011 Chatterjee et al AJG July 2016

24 Where should Mrs M be managed A)Cardiology B) AMAU under acute medicine C) GI ward D) Dedicated Bleed Unit E) Bed managers decide!

25 Sidhu R et al Eur J Gastro Hepatol 2009;8:861-5

26 Improving Patient Outcomes Reduced length of stay if dedicated care pathway implemented/managed by GI physicians Elderly patients greater risk of complications during endoscopy compared to the younger cohort-aspiration pneumonia, oversedation, hypoventilation, vasovagal episodes Risk minimised through adequate resuscitation and monitoring during and after sedation. Therapeutic procedures> complication compared to diagnostic procedures Chapman BL Br Heart J 1979;42: Podila PV et al Am J Gastroenterol 2001;96:208-19; Quirk DM et al Gastroenterology 1997;113: Sidhu EJGH 2009, Lim Endoscopy 2006

27 Corroborative Data Endoscopists Experience and Timing? >3000 gastroscopies (at least 100 UGIH) versus <1000 gastroscopies (between UGIH) Reduction in re-bleeding and transfusion rates Parente F et al World J Gastroenterol 2005;11: Sheffield data BSG 2013: In % (208/274) of endoscopic procedures for UGIH being performed by trainees compared with only 16% in 2011

28 Adrenaline Injection Mechanical Devices Ablative Techniques Haemospray

29 Multicentre SEAL survey (Survey to evaluate the application of haemospray in the luminal tract) Haemospray TC 325-novel haemostatic agent licensed for non variceal UGI bleeding. Adhering to bleeding site-mechanical tamponade, activating plts and coagulation factors promoting thrombus formation useful as monotherapy or rescue therapy Smith LA J Clin Gastro 2014 Yau Can J gastroenterol hepatol 2014

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31 Variceal Bleeding Resuscitation and airway management ( ±anaesthetic support )- ongoing haematoemesis/encephalopathy/agitation Early Antibiotics Vasopressors (terlipressin 2mg) MELD score (model of end stage liver disease using bilirubin, creatinine and INR to predict mortality ) & Child Pugh scores- scores relate to mortality. Endoscopy-banding of oesophageal varices /glueing of gastric varices PPI-to reduce post banding ulceration Other Options: Minnesota tube/ Danis stent / TIPPS

32 Pt with acute GI Bleeding should only be admitted to hospitals with 24/7 access to onsite endoscopy/ interventional radiology ( on site/ formal network) / surgery and critical care Separation of upper 7 lower GI bleeds should cease with a Lead clinician for integrated pathways of all major GI bleeds Ongoing care of major bleeds should rest with a named consultant to ensure timely investigations and reduce unnecessary transfusions Clear plans for re-bleeding at time of diagnostic/therapeutic procedure. NCEPOD 2015

33 STILL BLEEDING! OPTIONS 2 nd Look endoscopy Surgery Angiography

34 Lower GI Bleeding Definition-haematochezia History-any weight loss, pain, symptoms of obstruction, NSAID use/ history of radiotherapy Higher prevalence in elderly 80-85% cases stops spontaneously Causes Diverticular disease (more prevalent in left colon) Vascular lesions (right colon) Tumour Ischaemic colitis (watershed areas splenic flexure, right colon) haemorrhoids Management resuscitation Endoscopy Angiography

35 Obscure GI bleeding Ongoing overt/ obscure bleeding where OGD, colonoscopy-normal and SB source suspected Capsule Endoscopy

36 Summary Risk stratification, Adequate resuscitation is key to management of GI haemorrhage Over-transfusion 2 fold increase in rebleeding and increases mortality. Careful consideration of antiplatelet and anticoagulation due to high CVS events and mortality but lower rebleeding.

37 Thank you