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  

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  

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  

Initial  assessment  

Her  score:  0    Likelihood  of  needing  endoscopic  interven6on  or  transfusion:  0%-­‐very  low  

Pang  S.  Gastrointest.  Endosc.  71,  1134–1140  (2010)  

hIp://gihep.com/calculators/bleeding/blatchford-­‐score/  

Glasgow-­‐  Blatchford  Score  

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  

Stanley  A.2009    Lancet  373,  42–47  (2009)    

Pang  S.  Gastrointest.  Endosc.  201071,  1134–1140    

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    

Rockall  score  

Rockall  Gut  1996;38:  316      

Rockall  scale  

Rockall  Gut  1996;38:  316            

hIp://gihep.com/calculators/bleeding/rockall-­‐score/  

Predictive  value  of  the  Rockall  score  Score   Mortality  %   Mortality  with  re-­‐

bleeding  %  

1   0   0  2   0   0  3   5   5-­‐10    4   5-­‐10   15-­‐25  5   5-­‐10   15-­‐25  6   5-­‐10   15-­‐25  7+   10-­‐35   25-­‐50  

Rockall  Gut  1996;38:  316      

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  <  50000  :  YES  

•  Consider:  Fresh  frozen  plasma  prothrombin  time  (INR)  or  a  greater  than  1.5  times  normal  or  on  coumadin  

The  danger  of  over  transfusion  of  blood  

Villanueva  New  Engl  J  Med  2013;368:11  

The  potential  value  of  an  NG  aspirate  

Barkun  A.  Ann  Intern  Med.  2003;139(10):843-­‐857  

Intravenous  PPIs:  yes  or  no?  

Intravenous PPI therapy can change the need for endoscopic therapy

Lau New Engl J Med 2007;356:1631

Risk of recurrent bleeding

Lau New Engl J Med 2007;356:1631

Intravenous PPIs in Peptic ulcer bleeding

Sung  J  Ann  Intern  Med.  2009;150(7):455-­‐464.  

Outcomes in RCT of iv PPIs

Parameter Esomeprazole  N=375

Placebo  N=389

P  value

Rebleed  <72  h 5.9% 10.3% P=0.0206 Rebleed  <7  days 7.2 12.9 P=0.0095 Re-­‐bleed  <30  days 2.7% 5.4% P=0.0092 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):455-­‐464.  

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.  2004  ;99:1233-­‐7;  Clin  Gastroenterol  Hepatol.  2005  Dec;3(12):1207-­‐14  

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):843-­‐857   Sreedharan  A  Cochrane  reviews  2012  

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  

Endoscopy:  Intervention  and  risk  assessment  

The  value  of  the  endoscopic  classi^ication:  

Discontinue  aspirin?    

Sung  J  Ann  Intern  Med.  2010;152:1-­‐9.  

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  

H pylori eradication vs anti-secretory therapy in rebleeding

Cochrane  Trials  database  accessed  9/2008  

•  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  

H  pylori:  Important  points  

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  

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  

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  

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