Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence

1. Dr Jessie Chan CMC Joint Hospital Surgical Grand Round 21 Apr 2012 Management of non-varicealupper GI bleeding (NVUGIB) - An update review of current evidence

2. Upper GI bleeding • Major prevalent and clinically significant condition world wide • Important cause of hospitalization and mortality • Clinical and economic burden • Overall incidence decreases • Mortality remains unchanged M.E. van Leerdam. Epidemiology of acute upper gastrointestinal bleeding. Best Practice & Research Clinical Gastroenterology 2008.

3. Overview • Pre-endoscopy proton pump inhibitor (PPI) • Second look endoscopy • Post-endoscopy PPI • Antiplatelet agents • Transarterial embolization

4. Pre-endoscopy PPI • High-dose PPI infusion accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy RCT N = 638 Lau JY et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007.

5. Meta-analysis 6 RCTs N = 2223 Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.

6. Meta-analysis 6 RCTs N = 2223 Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.

7. Pre-endoscopy PPI • Safe drug profile • Cost effective • Not used to replace early endoscopy within 24 hours Joseph JY Sung et al. Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut 2011.

8. Second-look endoscopy Meta-analysis 5 RCTs N = 998 • Second-look endoscopy with thermal coagulation showed modest effects in reducing recurrent bleeding Tsoi KK et al. Second-look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: a meta-analysis . J Gastroenterol Hepatol 2010.

9. Second-look endoscopy • Chiu PW et al. RCT 2006. N = 201. • IV omeprazole with a single endoscopy vsroutine second-look endoscopy without PPI • Recurrent bleeding 8.2% vs 8.7%(RR = 1.07, 95% CI = 0.43–2.66) • High-dose PPI obviated the need for second-look endoscopy as a routine procedure

10. Second-look endoscopy • Not cost effective • Generally not recommended as a routine • Selective in high-risk patients

11. Post-endoscopy PPI • High risk stigmata • IV bolus then infusion of high-dose PPI(e.g. 80mg bolus  8mg/hr infusion) • Raise pH of the stomach • Stabilize blood clot • Prevent further mucosal damage

12. Meta-analysis 24 RCTs N = 4373 • Reduced rebleeding Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.

13. Meta-analysis 24 RCTs N = 4373 • Reduced surgery Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.

14. Post-endoscopy PPI • High-dose oral PPI • Javid et al. Am J Med 2001. RCT. N = 166. • 40mg Q12H x 5/7 • Kaviani MJ et al. Aliment Pharmacol Ther 2003. RCT. N =149. • 20mg Q6H x 5/7 • Reduced rate of rebleeding, need for surgery and transfusion, shorter hospital stay • Cost effective Joseph JY Sung et al. Gut 2011.

15. Aspirin • Lack of clinical data to provide guidance on a safe period of discontinuation • 80% of rebleeding occurred in the first 3 days after index bleeding • Restart aspirin at day 3-5 with stable haemodynamics Joseph JY Sung et al. Gut 2011.

16. Clopidogrel • Similar antiplatelet effect as aspirin • Resume after 3-5 days Joseph JY Sung et al. Gut 2011.

17. Dual antiplatelet • No evidence to guide treatment • Individualized • Type of stent • Drug-eluting vs bare metal stent • Duration of stent • Stent placed within 30 days carries higher risk of thrombosis • Ease of endoscopic haemostasis Joseph JY Sung et al. Gut 2011.

18. Recurrent bleeding • Second attempt at endoscopic therapy • Few complications • Reduced need of surgery • Did not increase mortality • Surgical intervention • Better chance to secure haemostasis Lau JY et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999.

19. Transarterial embolization (TAE) • Superselective cannulation +/- embolization of gastroduodenal, left gastric or splenic artery • Guided by clips placed in endoscopy

20. Wong TC et al. Gastrointest Endosc 2010 .

21. Retrospective study Gastrointest Endosc 2010

22. Transarterial embolization (TAE) • No solid evidence to support embolization as an alternative to surgery • Considered as an alternative • High surgical risk • Expertise available Joseph JY Sung et al. Gut 2011. Alan N. Barkun et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of Internal Medicine 2010.

23. Conclusion • UGIB is a common and important condition • Consider to start PPI early before the first endoscopy • Post-endoscopy high-dose oral PPI may be useful in Asian

24. Conclusion • Aspirin and clopidogrel may be resumed as early as 3-5 days after the index bleeding • TAE may be considered as an alternative to surgery in recurrent bleeding

25. Thank you!