Gastrointestinal bleeding

1. Gastrointestinal bleeding Dr Nahla Azzam MRCP,FACP Associate Professor of Medicine

2. What is the common cause for upper GI bleeding?

3. What is the most appropriate first step in approaching patient with UGIB?

4. What is the accepted Hb level pre-endoscopy?

5. When we can resume aspirin after controlling the bleeding?

6. History • What are the essential questions Almadi et al. JAMA 2011;306:2367-74.

7. Physical exam • What are the cardinal signs?

9. Epidemiology • 48 to 160 cases per 100 000 adults per year • Mortality generally from 10% to 14% Barkun et al. Ann Intern Med 2010;152:101-13.

10. Ahmed ME et al. J R Coll Physicians Lond 1997; 31 (1):62-4 • Alam MK. Saudi J gastroenterol 2000;6:87-91 • Al Karawi MA et al. Ann Saudi Med 1995; 15(6):606-8 Longstreth GF. Am J Gastroenterol 1995; 90:206

11. Causes of UGIB Gibson et al. Gastrointest Endosc Clin N Am 2011;21:583-96.

12. Gralnek et al. N Engl J Med 2008;359:928-37.

13. Gralnek et al. N Engl J Med 2008;359:928-37.

14. Gralnek et al. N Engl J Med 2008;359:928-37.

15. Gralnek et al. N Engl J Med 2008;359:928-37.

16. Acosta et al. Gastrointest Endosc Clin N Am 2011;21:555-66.

17. Acosta et al. Gastrointest Endosc Clin N Am 2011;21:555-66.

18. Acute UGIB is a common medical emergency that has 11% hospital mortality rate • Despite advances in management, mortality has not significantly improved Rosenstock SJ, Møller MH, Larsson H, et al. Am J Gastroenterol 2013; 108:1449

19. 2004 - 2006 2010 - 2011

20. Steps of Management

21. Pre-endoscopic management Initial assessment and risk stratification

22. 4- Risk Stratification Glasgow- Blatchford Score (GBS) Rockall Score Modified-GBS AIMS65

23. Urea CBC Physical History Bardou et al. Nat Rev Gastroenterol Hepatol 2012;9:97-104.

24. History Physical History Hearnshaw et al. Aliment Pharmacol Ther 2010;32:215-24.

25. Steps of Management

26. IV Fluid Resuscitation

27. IV Fluid Resuscitation Then

28. 2- Hemodynamic status and resuscitation Baradarian R et al. Am J Gastroenterol 2004; 99: 619 – 622 Early intensive hemodynamic resuscitation of patients with acute UGIB has been shown to significantly decrease mortality

29. Steps of Management

30. 3- Blood Transfusions Marik PE, Corwin HL. Crit Care Med 2008; 36: 2667 – 2674 Restellini S, Kherad O, Jairath V et al. Aliment PharmacolTher 2013; 37: 316 – 322 The role of transfusion in clinically stable patients with mild GI bleeding remains controversial, with uncertainty at which hemoglobin level transfusion should be initiated Literature suggesting poor outcomes in patients managed with a liberal transfusion

31. 3- Blood Transfusions (cont’d) Villanueva C, Colomo A, Bosch A et al. N Engl J Med 2013; 368: 11 – 21 The restrictive RBC transfusion had significantly improved survival and reduced rebleeding

32. 3- Blood Transfusions (Cont’d) 7 gm/dl 9 gm/dl

33. 3- Blood Transfusions (Cont’d)

34. Patients receiving anticoagulants Correction of coagulopathy is recommended Endoscopy should not be delayed for a high INR unless the INR is supratherapeutic Barkun et al. Ann Intern Med 2010;152:101-13.

35. Pre-endoscopic pharmacological therapy

36. Preendoscopic PPIs • HAS NOT been shown to affect rebleeding, surgery, or mortality • HAS decreased the need for intervention • HAS a supportive cost-effectiveness analyses • HAS an excellent safety profile • This suggest that these agents may be useful Barkun et al. Ann Intern Med 2010;152:101-13.

37. Preendoscopic PPI May be even more beneficial in situations in which early endoscopy may be delayed or when available endoscopic expertise may be suboptimal Barkun et al. Ann Intern Med 2010;152:101-13.

38. Endoscopic management

39. Timing and need for early endoscopy • Definition of early endoscopy • Ranges from 2 to 24 hours AFTER INITIAL PRESENTATION • May need to be delayed or deferred: • Active acute coronary syndromes • Suspected perforation Barkun et al. Ann Intern Med 2010;152:101-13.

40. A VERY low Blatchford score • Can identify very low-risk patients • Unlikely to have high-risk stigmata • Unlikely benefit from endoscopic therapy • Can be safely managed as outpatients without the need for early endoscopy • HOWEVER, this remains controversial Barkun et al. Ann Intern Med 2010;152:101-13.

41. Early endoscopy • Reductions in length of hospital stay in patients at low risk, high risk, and combined patient groups • Decreased need for surgery in elderly patients Barkun et al. Ann Intern Med 2010;152:101-13.

42. Predictors of active bleeding • Fresh blood in the NGT • Hemodynamic instability • Hemoglobin level < 80 g/L • Leukocyte count >12 109 cells/L • They need very early endoscopy (<12 hours) Barkun et al. Ann Intern Med 2010;152:101-13.

44. Kovacs et al. Gastrointest Endosc Clin N Am 2011;21:681-96.

45. Kovacs et al. Gastrointest Endosc Clin N Am 2011;21:681-96.

46. Kovacs et al. Gastrointest Endosc Clin N Am 2011;21:681-96.

47. Kovacs et al. Gastrointest Endosc Clin N Am 2011;21:681-96.

48. Pharmacological therapy

49. PPIs • Compared to placebo or H2RAs with or WITHOUT endoscopic therapy PPIs reduced • Rebleeding • Surgery • NOT mortality Barkun et al. Ann Intern Med 2010;152:101-13.

50. PPIs cont. • Compared to placebo or H2RAs with or WITH endoscopic therapy High dose PPIs reduced • Rebleeding • Surgery • Mortality Barkun et al. Ann Intern Med 2010;152:101-13.