an algorithmic approach to ugi bleeding

1. An Algorithmic Approach to UGI Bleeding Glenn M. Eisen, et al. Gastrointest Endosc 2001; 53(7): 853-859 presented by Ri???

2. UGI Bleeding A common medical presentation Endoscopy: an important early intervention Early endoscopy: Reduce adverse outcomes Choose appropriate care to prevent rebleeding Lee JG, et al. Gastrointest Endosc 1999; 50(6): 755-61

3. Initial evaluation (1) Possible etiology of bleeding Peptic ulcer, Mallory-Weiss tears, esophagitis, esophageal/gastric varices Morbidity/mortality associated with varices: still high, need timely therapeutic intervention Complicating factors Age, use of anticoagulants, coagulatory diseases, NASID use

4. Initial evaluation (2) Source of bleeding: upper or lower NG tube: help in identifying the source Lavage: allow the stomach to be cleared of blood Extent of blood loss Orthostatic changes in BP: significant volume depletion, need prompt resuscitation

5. Management Acid suppression therapy Pre-endoscopy risk assessment Endoscopy Actively bleeding ulcers, ulcers with nonbleeding visible ulcers

6. Acid Suppression Therapy (1) IV H2 blocker alone: no significant improvement on short-term outcomes, e.g. rebleeding rates Collins R, et al. NEJM, 1985; 313: 660-6 Maintenance use of H2 blocker after ulcer healing: long-term rebleeding rates are reduced. Jensen DM, et al. NEJM, 1994; 330(6): 382-6 Successful H. pylori eradication: reduce long-term rebleeding rates Laine LA. Am J Med 1996; 100(5A): 52S-57S

7. Acid Suppression (2): PPI use Omeprazole PO in pts who did not receive endoscopic therapy: The need for surgery and transfusion: lower No significant change in mortality Khuroo MS, et al. NEJM 1997; 336(15): 1054-8 Omeprazole IV in pts who had receive endoscopic therapy: Recurrent bleeding rates: 6.7% vs. 22.5% No difference in surgical procedures or mortality Lau JY, et al. NEJM 2000; 343(5): 310-6

8. Acid Suppression Therapy (3) Summary It may play an adjunctive role in short-term management of pts with UGI bleeding It should NOT be the ONLY intervention!!

9. Pre-endoscopy Risk Assessment (1) Definition of “early” endoscopy A significant controversy In general: within 24 hrs of presentation Emergent endoscopy For pts who are hemodynamically unstable Improve short-term morbidity/mortality

10. Pre-endoscopy Risk Assessment (2) Parameters of risk assessment Clinical signs: shock, massive hemorrhage Endoscopic findings: an important guide to predict the risk of rebleeding and the appropriate setting for post-endoscopic management Establishment of scoring systems

11. Pre-endoscopy Risk Assessment (3) Clinical & endoscopic data are both used: identifying pts at low risk for rebleeding and who can be managed in an outpatient setting. Longstreth GF, et al. Gastrointest Endosc 1998; 47(3): 219-22 4 variables (hemodynamics, time from bleeding, comorbidity, endoscopic finding): reduce hospital LOS in low-risk pts from 4.6 days to 2.9 days Hay JA, et al. JAMA 1997; 278(24): 2151-6

12. Pre-endoscopy Risk Assessment (4) Summary--benefit of risk assessment: Shorter hospital length of stay Reduction in cost of care Common predictors of rebleeding Older age Hemodynamic instability Comorbid disease (e.g. CAD, CHF, CRI) Anticoagulants use/ coagulopathy Specific endoscopic findings (e.g. malignancy) High-risk lesion in scope (e.g. arterial bleeding)

13. Endoscopy (1) Hemostatic techniques: Laser: limited use, expensive cost Thermal contact: widely available, obvious reduction in adverse outcomes Injection therapy: epinephrine and sclerosant solutions, easily use Complications: perforation, worsening of bleeding

14. Endoscopy (2) A net benefit in the management of pts with high-risk lesions Improved medical outcomes with therapeutic endoscopic interventions ?significantly lower healthcare costs Gralnek IM, et al. Gastrointest Endosc 1997; 46(2): 105-12

15. Endoscopy (3): special conditions Esophageal or gastric varices: sclerosis or banding AVM, Mallory-Weiss tears: electrocautery with or without epinephrine and/or sclerosants Peptic ulcers: a test for H. pylori ? positive H. pylori eradication reduces long-term rate of rebleeding.

16. Actively bleeding ulcers (1) Actively bleeding ulcers & ulcers with nonbleeding visible vessels: Seen in up to 35% of pts with ulcers at the time of endoscopy Greatest risk of poor outcomes and rebleeding Rollhauser C, et al. Endoscopy 1999; 31(1): 17-25

17. Actively bleeding ulcers (2) Endoscopic therapies: Injeciton of epinephrine and/or sclerosants, electrocautery, heater probe Reduction in rebleeding rates After endoscopy: Observation in acute care setting Rebleeding can occur in up to 20% of pts, within 48-72 hrs. Saeed ZA, et al. Endoscopy 1996; 28: 288-94

18. Actively bleeding ulcers (3) If rebleeding occurs: Repeat endoscopy, angiography, surgery Lau JYW, et al. (1999): 48 pts undergoing endoscopic retreatment vs. 44 pts receiving surgery 35 of 48 pts had long-term control of bleeding (73%). 13 of 48 pts the need for surgery and was associated with fewer complications. Lau JYW, et al. NEJM 1999; 340: 751-6

19. Actively bleeding ulcers (4) Ulcers with overlying clots: Removal of the clot may be beneficial. It can be removed by simple irrigation, to expose the underlying ulcer bases. Laine L, et al. Gastrointest Endosc 1996; 43(2): 107-10

22. Thank You for Your Attention 93/01/23