The Overall Approach to the Management of UGIB:

Dr.Mohamed Al-Shekhani

RESUSCITATION IN THE ER:Initial Assessment &Fluid Resuscitation

• The initial priority is of prompt & repeated assessment of ABC, as patients are at risk of HD shock &airway compromise.

• IV access should be achieved with at least 2 large-bore cannulae

• Patients with active bleeding should be monitored in a high-dependency environment with pulse oximetry,cardiac monitoring, automated BP readings,close monitoring of UO &ideally, CVP .

• All should be blood typed & cross-matched with blood sent for hemoglobin, hematocrit, platelets, coagulation time, &electrolytes.

• HD shock is associated with an increased mortality& prompt restoration of circulating volume takes priority over endoscopy.

• Fluid challenge with crystaloids to commence initial volume restoration prior to blood components for (NVUGIB) is essential.

• Colloids or albumin are preferred in patients with cirrhosis & ascites.

RESUSCITATION IN THE ER:Use of Blood Components

• The purpose is to correct global or regional oxygen delivery& to improve hemostasis.

• 43% of AUGIB received red blood cell (RBC) transfusion.

• Patients requiring massive transfusion (>10 units of packed red cells or loss of >1 circulating volume) are likely to develop a dilutional coagulopathy &will require transfusion of platelets & fresh frozen plasma.

• Patients with (Hb) of >8 g/dL, transfusion within 12 hours was associated with *2 increase in rebleeding.

• A transfusion can probably be withheld in the presence of Hb 7- 8 g/dL, provided there is no active bleeding& no evidence of comorbid CVD.

RESUSCITATION IN THE ER:Correction of Coagulopathy

• Even after excluding anticoagulants use& cirrhosis, 6.2% had a coagulopathy(multifactorial&measure of disease severity )& associated with an increase in mortality & rebleeding.

• Correcting INR to < 1.8 as part of intensive resuscitation led to lower mortality & fewer MI.

• All NVUGIB patients should undergo a routine coagulation screen &the presence of a coagulopathy should prompt correction with appropriate blood components(eg, fresh frozen plasma, prothrombin complex).

• This should not delay the performance of early endoscopy.

• limited data also suggest that endoscopic hemostasis can be safely performed in patients with an elevated INR as long as it is not supratherapeutic (ie, up to around 2.5).

• The INR does not seem to predict bleeding risk in patients with cirrhosis presenting with UGIB.

RESUSCITATION IN THE ER:NGT

• Its use before endoscopy in the ER remains controversial.

• Benefits:

• 1. To confirm an UGI source of bleeding(can still miss up to 15%)

• 2. Most useful indication is as a prognostic index for identifying high-risk lesions as presence fresh red blood in the NGT aspirate found to be an independent predictor of adverse outcome & predictor of high-risk lesions in patients who are hemodynamically stable without evidence of hematemesis.

• 3.To facilitate lavage of the upper GI tract to improve mucosal views at subsequent endoscopy.

RESUSCITATION IN THE ER:Risk stratification scoring:

• All should be risk assessed by scoring systems, using basic clinical, lab&endoscopic stigmata for stratification into low-risk & high-risk categories for rebleeding, mortality&need for therapeutic endoscopic intervention.

• Low-risk patients suitable for early discharge from hospital & high-risk patients who should be monitored in a high-dependency area with access to early endoscopy & specialist care.

• The most extensively validated scores are the Rockall & Blatchford scores .

• The preendoscopic Rockall &Blatchford scores use only clinical &laboratory data whereas the complete Rockall score also uses endoscopic data to predict rebleeding or mortality.

• Complete Rockall score appears to be superior to both the preendoscopy Rockall score a&Blatchford score in predicting mortality & rebleeding.

RESUSCITATION IN THE ER:Risk stratification scoring:

• Patients with a preendoscopy Rockall score of zero should be considered for early discharge or even non admission with early outpatient assessment.

• Those patients with a preendoscopy Rockall score > 0 should undergo inpatient endoscopy for a full assessment of bleeding risk.

• Blatchford score is more useful than the Rockall score in identifying low-risk patients who do not require therapeutic endoscopy,specially those patients with a score of zero may be safely triaged from the ED to outpatient management.

RESUSCITATION IN THE ER:Risk stratification scoring:

RESUSCITATION IN THE ER:Risk stratification scoring:

RESUSCITATION IN THE ER:Risk stratification scoring:

RESUSCITATION IN THE ER:Risk stratification: other than scoring systems

• Age: mortality more for older than 60 years & even more for>75.

• HD shock: Hypotension & tachycardia is associated with >*3 increase in mortality&increase need for endoscopic intervention.

• Presentation with hematemesis or hematochezia: hematemesis is associated with a twofold risk of mortality & hematochezia, with a *2 risk of mortality, rebleeding& rates of surgical intervention.

• Inpatient status at the time of developing a bleed: associated with *3 increased risk of mortality compared with new admissions

• High BUN:associated with an increase need for endoscopic interv

• A large ulcer size (>2 cm ), specific locations (lesser wall curve or on the posterior duodenal wall)& those with high-risk stigmata, all predictors of an increased risk of rebleeding &mortality.

• Endoscopic stigmata ( Forrest classification)valuable in predicting the risk of rebleeding; Class IA, IB, IIA& IIB are high risk, whereas Class IIC & III are low-risk

RESUSCITATION IN THE ER:Risk stratification: other than scoring systems

RESUSCITATION IN THE ER:USE OF PHARMACOLOGIC AGENTS PREENDOSCOPY:PPI

• The use of preendoscopic proton-pump inhibitor (PPI) therapy is very common in clinical(43%)

• Maintaining gastric pH > 6 may optimize platelet aggregation & clot formation at sites of mucosal injury.

• A Cochrane review:comparing PPI with control administrations (placebo or H2 antagonists) found no evidence that preendoscopic administration of PPIs led to a reduction in rebleeding, mortality, or need for surgery, but significantly reduced the proportion of patients with high-risk stigmata at index endoscopy as well as the need for endoscopic intervention.

RESUSCITATION IN THE ER:USE OF PHARMACOLOGIC AGENTS PREENDOSCOPY:PPI

• Not for all but most suitable for:

• Those patients in whom early endoscopy may be delayed or where endoscopic expertise is not available within 24 hours

• When the patient is more likely to be bleeding from a nonvariceal source or a high-risk lesion (hematemesis, bloody NGT).

• PPI: either an oral or IV PPI, with greater evidence base for IV specially for patients who are vomiting.

RESUSCITATION IN THE ER:USE OF PHARMACO AGENTS PREENDOSCOPY: Prokinetics

• The preendoscopic administration of a prokinetic IV erythro or metochlopromide significantly reduced the need for repeat endoscopy ,but did not improve other clinically important outcome measures.

• Erythromycin should be considered more specifically for patients likely to have blood in the stomach at the time of early endoscopy.

• A prior electrocardiogram is also recommended, as erythromycin can prolong the QT interval.

RESUSCITATION IN THE ER:PHARMACO AGENTS PREENDOSCOPY: ANTIFIBRINOLTYICS• At present there is insufficient evidence to recommend TXA in the

treatment of NVUGIB&large-scale RCT will be required to address this question.

RESUSCITATION IN THE ER:PHARMACO AGENTS PREENDOSCOPY: SMST/OCTT

• Current international recommendations state that somatostatin or octreotide are not recommended in the routine management of patients with acute NVUGIB.

• A meta-analysis found a reduced risk for rebleeding.decreased need for surgery ,but this was not statistically significant

• It might be useful for patients who are bleeding uncontrollably while awaiting endoscopy or surgery, or for whom surgery is contraindicated

RESUSCITATION IN THE ER:PREENDOSCOPY: Optimal time to endoscope

• Guidelines recommend early endoscopy for all patients ,within 24 hours of presentation, performed by endoscopists skilled in all modalities of hemostasis in appropriate clinical areas with skilled support staff, which is especially important when endoscopy is to be performed out of working hours.

• Earlier endoscopy (<24 hours) has not been shown to be useful, although in very high-risk patients with high Blatchford scores, such an approach may be useful after optimal initial resuscitation.

RESUSCITATION IN THE ER:PREENDOSCOPY: Optimal time to endoscope

• Early endoscopy( within 24 hours): benefits

• Improvement in other important clinical end points.

• It allows prompt risk stratification & early discharge of those patients with low-risk endoscopic stigmata &no serious concurrent co-morbidity.

• It may enable early &targeted endoscopic hemostasis in higher-risk patients who are actively bleeding or with high-risk stigmata of bleeding.

• It has been shown to reduce length of hospital stay&/or units of blood transfused in both low-risk & high-risk groups.

• There is no good data to see effect on mortality.

RESUSCITATION IN THE ER:POSTENDOSCOPY MANAGEMENT: PPI

• High-dose IV PPI (80 mg bolus followed by 8 mg/h infusion over 72 hours) should be administered to patients with high-risk stigmata who have received successful endoscopic therapy.

• This reduces the incidence of rebleeding&need for surgery but not mortality.

• In those patients with active bleeding or a nonbleeding visible vessel who received endoscopic therapy, high-dose PPI led to a reduction in rebleeding ,need for surgery & mortality.

RESUSCITATION IN THE ER:POSTENDOSCOPY MANAGEMENT: Test&treat H Pylori

• All patients with bleeding peptic ulcers should be tested for H pylori & receive eradication therapy if it is positive.

• Eradication of H pylori was more effective than PPI therapy alone in prevention of recurrent bleeding from peptic ulcers.

• There is an increased false-negative rate using any diagnostic method.

• H pylori eradication must also be confirmed by subsequent testing.

RESUSCITATION IN THE ER:POSTENDOSCOPY MANAGEMENT: General in-hospital management.

• Most high-risk ulcers will take at least 72 hours to become downgraded to low-risk lesions after endoscopic therapy & high-dose PPI.

• So patients with high-risk stigmata should be hospitalized for 72 hours, &nursed in a monitored setting for the first 24 hours, as 80% of cases of rebleeding is likely to occur during this period.

• Patients at low risk of rebleeding can be fed within 24 hours of endoscopy, started on a daily oral dose of PPI&can be discharged after 1 or 2 days, depending on comorbid conditions

• Patients who present bleeding (ASA)-related ulcer should be restarted on the ASA as soon as its benefits outweigh the risks, which should be determined on a case-bycase basis; this usually is within 5 days of presentation.

RESUSCITATION IN THE ER:POSTENDOSCOPY MANAGEMENT: subsequent pharma management.

• After discharge, patients should be prescribed a once-daily oral PPI dose (in the case of bleeding esophagitis, twice-a-day dosing), the duration of which should be determined by the underlying etiology of the bleeding.

• Patients who have bled from ulcers while taking antithrombotic, NSAIDs or anticoagulant therapies need to have the benefits / risks reassessed, with appropriate consideration given to secondary prophylaxis.

Summary:

• Adequate resuscitation.

• Risk stratification .

• Early endoscopy to enable further risk stratification.

• Application of endotherapy to high-risk lesions to achieve hemostasis &downgrade stigmata.

• Injection of epinephrine alone is not optimal when treating all high-risk lesions which needs in addition one of the other endoscopic hemostatic modalities as APC or cliping.

• All endoscopic hemostasis should be complemented by a 72-hour infusion of high dose PPI.

• All patients should be tested for H pylori & treated if necessary,

• Secondary prophylaxis should be considered for appropriate patients.