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Kurdistan Board GEH J Club:Supervised by:

Dr. Mohamed AlshekhaniProfessor in Medicine

MBChB-CABM-FRCP-EBGH 2016

Introduction:• GIB the most common cause of hospitalization due to GI disease &

costs annually.• UGIB:bleeding from the esophagus, stomach, or duodenum, is

responsible for 50% or more of these hospitalizations.• Fatality decreased over past 20 ys 2.1-2.5 % USA - 10% in Europe.• Peptic ulcers, primarily due to HP or NSAIDs, occur in the stomach

or duodenum& are the most frequent cause of UGIB.• Erosions in the esophagus (GERD) or in the stomach or duodenum

(frequently due to NSAIDs) are also common sources • Mallory–Weiss tears, linear tears that usually occur on the gastric

side of the gastroesophageal junction, may cause severe bleeding , usually occur after retching or vomiting.

• Less common causes; neoplasms, vascular ectasias (GAVE), Dieulafoy’s (aberrant vessels in the mucosa), bleeding from the bile duct or pancreatic duct&aortoenteric fistulas,varices ; 1.9->30%.

Initial Assessment:

• Initially risk assessment is performed to determine the severity according to vital signs &patient factors.

• Tachycardia (HR≥100), hypotension (systolic BP≤100 mm Hg), age > 60 years, major coexisting conditions are associated with an increased risk of further bleeding & death.

• Risk-assessment tools are available &useful in identifying patients at very low risk, for discharge from ER &OP care for patients with a Glasgow–Blatchford score of 0, 0 - 1, or, in patients < 70 years of age, 0 - 2 ( on scale 0 -23 )with higher scores indicating higher risk)

• When hospitalized <1% such patients require intervention&< 0.5% die.

• Hb is a poor initial indicator of the severity, BZ it not drop immediately but takes hours.

Initial Therapy before Endoscopy:

• RBC transfusion recommended when Hb< 7 g with lower death, rebleeding, adverse events compared with a threshold of 9 g.

• For patients in HD stable condition who have preexisting CVD, transfusion recommended at Hb of < 8 g or with symptoms, or hypotension due to severe UGIB.

• PPI after presentation did not significantly reduce the risks of further bleeding, surgery, or death,but associated with a decrease in the frequency of high-risk endoscopic findings (active bleeding, a nonbleeding visible vessel, or an adherent clot)&need for endoscopic therapy.

• Some recommend high-dose IV, others “ PPI may be considered” &others recommend clinicians not administer PPI.

• Erythromycin (250 mg IV 30 minutes before endoscopy) increases gastric motility & improves visualization at endoscopy,decreased the need for blood transfusion& repeat endoscopy.

Use of NGT:

• Not required &not suggest a clinical benefit.• BZ Standard-bore nasogastric tubes probably do not allow sufficient

clearance of clots to substantially improve visualization of the gastric mucosa at endoscopy.

Endoscopy:

• Most should undergo endoscopy within 24 hours, after appropriate resuscitation/transfusion, as needed, to Hb> 7.

• Associated with reductions in the need for surgery, length of hospitalization, mortality.

• Most patients with a low clinical risk (normal BP,HR, no major coexisting conditions) should undergo endoscopy as soon as possible during routine clinical hours.

• 40-45% who undergo endoscopy within 2 - 6 hours have low-risk endoscopic findings that allow discharge, thereby reducing costs.

• Endoscopy within 12-13 hours in patients with high clinical risk• (Glasgow–Blatchford score ≥12, bloody NGT, hypotension,

tachycardia) may be associated with improved outcomes.• Endoscopic features of ulcers are key in predicting risk&

determining management strategies.

Endoscopy:

• Endoscopic features of ulcers predicts risk& determining management strategies.

• Rates of further bleeding are highest among patients with active bleeding,nonbleeding visible vessels&adherent clot .

• If endoscopic treatment is not provided, serious further bleeding occurs in 25% with actively oozing hemorrhage, 35% with non-bleeding visible vessels&>60% with actively spurting hemorrhage.

• Flat, pigmented spots& clean-base ulcers, detected at endoscopy In 70% of patients with ulcer bleeding, associated with low rates of serious rebleeding (5.6% , 0.5%, respectively)

•

Endoscopy:

• Endoscopic therapy with inj (epinephrine or alcohol), thermal (bipolar electrocoagulation probes or heat probes), or clips is performed in ulcers with active bleeding or a non-bleeding visible vessel with risk reductions in further bleeding of 58% among active bleeding & 20% among nonbleeding visible vessels.

• Endoscopic therapy may be considered for ulcers with adherent clots& If bleeding recurs, endoscopic therapy should be repeated.

• Endoscopic re-intervention in rebleeding after endoscopic therapy, surgery avoided in 73% of cases & adverse events were significantly less common with endoscopic therapy than with surgical therapy.

• Transcatheter arterial embolization or surgery is performed if repeat endoscopic therapy fails.

• Bleeding or perforation occur in 0.5% with endoscopic therapy.• Endoscopic therapy also used for vascular ectasias, Dieulafoy’s,

neoplasms&actively bleeding Mallory–Weiss tears.

Endoscopy:

• In patients with ulcers or erosions, biopsy should be obtained from lesion-free areas of the gastric body & antral mucosa for H. pylori infection,with83% sensitivity &100% specificity &If negative, subsequent retesting (e.g., with a stool test or breath test) is needed BZ of decreased sensitivity during UGIB.

Care after Endoscopy:

• Patients with ulcers&high-risk endoscopic findings receive an• IV Bolus PPI(80 mg) followed by a continuous infusion (8 mg / hour)

for 72 hours,significantly reduced risks of further bleeding, the need for surgery& mortality.

• Intermittent iIV or oral PPI may be used in place of continuous infusion.

• The initial oral or IV bolus of 80 mg followed by 40 - 80 mg twice daily for 72 hours suggested.

• Patients who present with ulcers &high-risk endoscopic findings typically are hospitalized for 3 days after endoscopy if they have no further bleeding & no other reasons for hospitalization.

• Patients should be informed about symptoms of recurrence & the need to return to ER if any occur.

Care after Endoscopy:

• After discharge, patients with high-risk endoscopic findings & clinical factors(HD instability, older age, or a major coexisting condition) should receive twice daily PPI therapy for 2 weeks, followed by PPI once daily.

• Patients with low-risk clinical features (Normal HR/BP&no major coexisting conditions), low-risk endoscopic findings (clean-base ulcers, erosions, or non-bleeding Mallory–Weiss tears)&OP support can be discharged home after endoscopy& regular diet resumed .

• Once-daily PPI is recommended in patients with erosions or ulcers without highrisk endoscopic features.

Recurrent ulcer bleed Prevention:

• Strategies to prevent recurrent ulcer bleeding depend on the cause of 3 major causes of the ulcer.

• H. pylori 26% risk reduction by eradication.• NSAIDs (including aspirin) use • idiopathic ulcer.

Recurrent ulcer bleed Prevention:

• H Pylori:• Eradication of H. pylori should be confirmed after therapy with a

breath test, a stool test, or, if repeat endoscopy is performed for another reason, gastric biopsy.

• Patients must not receive bismuth or antibiotics for at least 4 weeks &should not receive PPI (Not H2RB) for at least 2 weeks before testing to avoid false negative results.

• Re-bleeding was only 1.3% among patients with confirmed eradication.

Recurrent ulcer bleed Prevention:

• NSAIDs Other Than Low-Dose Aspirin• Patients who have bleeding ulcers while taking NSAIDs should

discontinue NSAIDs permanently if possible. • If NSAIDs must be resumed, a combination of (COX-2)–selective

NSAID & PPI recommended.• LDAS:• For primary prophylaxis better to be stopped.• For secondary prophylaxis; Aspirin should be resumed 1- 7 days

after bleeding stops. • NSAIDs/Asp+ HP:• Co-therapy with PPI should be administered to reduce re-bleeding.• Eradication of H. pylori may reduce risk among patients who

receive low-dose aspirin.

Recurrent ulcer bleed Prevention:

• Idiopathic ulcer: • 42% incidence of re-bleeding at 7 years among patients who did not

have H. pylori infection, use NSAIDs, or have another uncommon identified cause of an ulcer (e.g., the Zollinger–Ellison syndrome or neoplasm)&who did not receive gastroprotective therapy.

• These patients should continue to receive once-daily maintenance therapy with PPI.