Management of patients with nonvariceal upper gastrointestinal bleeding

Introduction Upper gastrointestinal bleeding (UGIB) Incidence : 50 to 160 cases per 100,000 adult mortality : 10% to 14% Hospital stay and costs ( With/without complication) : 4.4/2.7 days & $5632/3402 Decreasing annual incidence of UGIB with unchanging or decreasing incidence of peptic ulcer bleeding  Increased use of NSAID or Aspirin

Introduction Upper gastrointestinal bleeding (UGIB) Resuscitation, risk assessment, and preendoscopy management Endoscopic management Pharmacologic management Nonendoscopic and nonpharmacologic in-hospital management Postdischarge, ASA, and NSAIDs

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Resuscitation, risk assessment, and preendoscopy management A1 & A4. Vital stablization & transfusion if Hb < 7mg/dL. Target Hb < 10g/dl < N Engl J Med. 999;340:409-17. >

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Resuscitation, risk assessment, and preendoscopy management A2 ,A3 & A7. Low risk Vs high risk patient. Glasgow-Blatchford bleeding score Low risk patient selection (Score 0)  possible outpatient management without early endoscopy High risk : Age>65years, Cr ↑, alcoholism, active cancer, APACHE>11, Detection of red blood from NG tube  poor outcome as an predictor of rebleeding and need emergency endoscopy Low risk of rebleeding among ulcer patient after endoscopy : promt discharge

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Resuscitation, risk assessment, and preendoscopy management A5. coagulopathy & endoscopy. : low platelet and prolonged INR ratio  not predict rebleeding Prolonged INR(>1.5) - predictor of mortality in UGIB Do not delay endoscopy from coagulopathy

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Resuscitation, risk assessment, and preendoscopy management A6. Promotility agents No routine use : Only for short NPO time & suspected large amount of blood and clots in stomach

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Resuscitation, risk assessment, and preendoscopy management A8. Preendoscopic PPI therapy PreendoscopicPPI : downstage the endoscopic lesion

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding B. Endoscopic management B1 & B2 . institution-specific protocols, skillful endoscopist and support staff B3. Endoscopy, ..When..? Barkun A, et al. : early endoscopy(< within 24 hours of presentation)  safe and prompt discharge at low risk improve patient outcome (mortality…) at high risk --Ann Intern Med. 2003;139:843-57

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding B. Endoscopic management B3. Endoscopy, ..When..? Target time to endoscopy : within 24hrs except 12hrs in active bleeding

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding B. Endoscopic management B4 & 7. How to manage endoscopically Forrest IIc & III (Minor SRH)  No endoscopic therapy Forrest I & IIa (Major SRH)  Endoscopic therapy

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding B. Endoscopic management B5 & 6. if clots on the ulcer bed..? : First, vigorous targeted irrigation….but still adherent ? Sung JJ, et al. – No rebleeding in both PPI + endoscopic therapy and PPI alone -- Ann Intern Med. 2003;139:237-43 Laine L, et al. – various rebleeding rate (5~35%) without endoscopic therapy high risk of rebleeding(concurrent illness)  Endoscopic therapy + high dose PPI Low risk of bleeding : high dose PPI therapy -- Clin Gastroenterol Hepatol. 2009;7:33-47

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding B. Endoscopic management B8. Epinephrine injection.  single agent injection in combination with other endoscopic hemostasis B9. What endoscopic coaptive therapy to choose. Bardou M, Youssef – No superior endoscopic coaptive method over another

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding B. Endoscopic management B10. how to combine…(Clip, thermocoagulaton, sclerosant, & epinephrine) : Efficacy, especially in high risk stigmata  Medical therapy < Epinephrine injection < Monotherapy ± Epi. injection B11. Second-look endoscopy. Improvement of hemostatic devices PPI use Cost reduction B12. If rebleeding occurs…  Endoscopic therapy first high risk of rebleeding 에서만 고려

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding C. Pharmacologic management C1. Histamine-2 receptor antagonists & Somatostatin and octreotide H2RA & somatostatin : Not recommended

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding C. Pharmacologic management C3 & C4. Proton pump inhibitor : Pivotal role in management of UGIB High dose PPI ( 80mg bolus ) + 8mg/hr infusion  reduce rebleeding, surgery, mortality(in high risk group) and cost

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding D. Nonendoscopic and nonpharmacologic in-hospital management D1 & 2 . Feeding & in-hospital care Laine L, Cohen - Time of refeeding : No influence on the hospital course of patients with a low risk of recurrent bleeding. -- Gastroenterology. 1992;102:314-6. Low risk stigmata : feeding within 24hours High risk stigmata : admission for at least 3 days with NPO Second look endoscopy feeding if trasition to low risk

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding D. Nonendoscopic and nonpharmacologic in-hospital management D3 & D4. If endoscopic therapy fails : Don’t hesitate to Seek surgery and percutaneous embolization

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding D. Nonendoscopic and nonpharmacologic in-hospital management D5 & D6. Helicobacter pylori H. Pylori (+)  irradication therapy and confirmation (-)  repeat

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding E. Postdischarge, ASA, and NSAIDs E1. NSAID use <N Engl J Med. 2002;347:2104-10.>.

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding E. Postdischarge, ASA, and NSAIDs E1. NSAID use E3. ASA Use Gastroenterology. 2008;130:A44 Restart on individual basis ( About 7 days)

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding E. Postdischarge, ASA, and NSAIDs E4. Clopidogrel(Plavix) use PPI  CYP2C19  clopidogrel Increased CVA & GI event Staggered schedule of medication

Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding