management of non-variceal upper gi bleeding (nvugib) - an update review of current evidence
DESCRIPTION
Dr Jessie Chan CMC Joint Hospital Surgical Grand Round 21 Apr 2012. Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence . Upper GI bleeding. Major prevalent and clinically significant condition world wide - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/1.jpg)
Dr Jessie ChanCMCJoint Hospital Surgical Grand Round21 Apr 2012
![Page 2: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/2.jpg)
Major prevalent and clinically significant condition world wide
Important cause of hospitalization and mortality
Clinical and economic burdenOverall incidence decreasesMortality remains unchanged
M.E. van Leerdam. Epidemiology of acute upper gastrointestinal bleeding. Best Practice & Research Clinical Gastroenterology 2008.
![Page 3: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/3.jpg)
Pre-endoscopy proton pump inhibitor (PPI)
Second look endoscopyPost-endoscopy PPIAntiplatelet agentsTransarterial embolization
![Page 4: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/4.jpg)
High-dose PPI infusion accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy
Lau JY et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007.
RCTN = 638
![Page 5: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/5.jpg)
Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.
Meta-analysis
6 RCTsN = 2223
![Page 6: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/6.jpg)
Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.
Meta-analysis
6 RCTsN = 2223
![Page 7: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/7.jpg)
Safe drug profileCost 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.
![Page 8: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/8.jpg)
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.
Meta-analysis
5 RCTsN = 998
![Page 9: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/9.jpg)
Chiu PW et al. RCT 2006. N = 201. IV omeprazole with a single endoscopy vs
routine 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
![Page 10: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/10.jpg)
Not cost effectiveGenerally not recommended as a
routineSelective in high-risk patients
![Page 11: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/11.jpg)
High risk stigmata IV bolus then infusion of high-dose
PPI(e.g. 80mg bolus 8mg/hr infusion)
Raise pH of the stomachStabilize blood clotPrevent further mucosal damage
![Page 12: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/12.jpg)
Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.
Meta-analysis
24 RCTsN = 4373
Reduced rebleeding
![Page 13: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/13.jpg)
Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.
Reduced surgery
Meta-analysis
24 RCTsN = 4373
![Page 14: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/14.jpg)
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 effectiveJoseph JY Sung et al. Gut 2011.
![Page 15: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/15.jpg)
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.
![Page 16: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/16.jpg)
Similar antiplatelet effect as aspirinResume after 3-5 days
Joseph JY Sung et al. Gut 2011.
![Page 17: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/17.jpg)
No evidence to guide treatment IndividualizedType of stent
Drug-eluting vs bare metal stentDuration of stent
Stent placed within 30 days carries higher risk of thrombosis
Ease of endoscopic haemostasisJoseph JY Sung et al. Gut 2011.
![Page 18: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/18.jpg)
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.
![Page 19: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/19.jpg)
Superselective cannulation +/- embolization of gastroduodenal, left gastric or splenic artery
Guided by clips placed in endoscopy
![Page 20: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/20.jpg)
Wong TC et al. Gastrointest Endosc 2010 .
![Page 21: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/21.jpg)
Gastrointest Endosc 2010 Retrospective
study
![Page 22: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/22.jpg)
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.
![Page 23: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/23.jpg)
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
![Page 24: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/24.jpg)
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
![Page 25: Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence](https://reader035.vdocuments.net/reader035/viewer/2022062810/56815d72550346895dcb7bd5/html5/thumbnails/25.jpg)