UPPER GI BLEEDING: A BOTTOM UP APPROACH

Sean Caine MD, CCFP-EM UHN Conference

November 3, 2014

Objectives At the end of this session you will be able to: •  Accurately diagnose patients with an UGIB

•  Identify low risk patients with an UGIB that can be safely discharged from the ED

•  Critically appraise the existing evidence for

treatments of UGIB in the ED

Etiologies

PUD 44%

MED 24%

Varices 8%

MWT 5%

Malignancy 3%

Other 5%

Unknown 11%

van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Practice & Research Clinical Gastroenterology. 2008 22(2). 209-224.

JAMA – Does this patient have a severe upper gastrointestinal bleed? Clinical Features

Positive LR (95% CI)

Negative LR (95% CI)

HISTORY Prior hx of UGIB 6.2 (2.8-14.0) 0.81 (0.74-0.89)

SIGNS Melenic stool on exam

25 (4-174) 0.52 (0.42-.64)

Nasogastric lavage with blood or coffee grounds

9.6 (4.0-23.0)

0.58 (0.49-0.7)

Clots in stool 0.05 (0.01-0.38) 1.2 (1.1-1.2) LABS

BUN : Cr Ratio > 35 7.5 (2.8-12) 0.53 (0.28-0.78) Srygley FD, Gerardo CJ, Tran T, Fischer DA. Does this patient have a severe

upper gastrointestinal bleed? JAMA. 2012. 307 (9): 1072-1079

Glasgow-Blatchford Low Risk Score

Clinical Features Score

BUN (mmol/L) <6.5 0

Haemoglobin (gm/L) MALES FEMALES ≥ 130 ≥ 120 0

Systolic BP (mmHg) ≥ 110 0

Heart Rate (bpm) < 100 0

Absence of Melena Syncope Hepatic Disease CHF

0

Need for intervention or death by GBS score

Stanley  AJ,  Ashley  D,  Dalton  HR  et  al.  Outpa6ent  management  of  pa6ents  with  low-­‐risk  upper-­‐gastrointes6nal  haemorrhage:  mal6centre  valida6on  and  prospec6ve  evalua6on.  The  Lancet.  2009  373:42-­‐47.  

Treatment  

Cochrane Database Syst Rev. 2010 Jul 7;(7):CD005415. doi: 10.1002/14651858.CD005415.pub3.

PPI Treatment Bottom Line Reduces stigmata of liver disease and need for endoscopic intervention No reduction in mortality, rebleeding, or surgery Insufficient data for decreases in hospital stay or transfusion

Cochrane Database Syst Rev. 2008 Jul 16;(3):CD000193. doi: 10.1002/14651858.CD000193.pub3.

Octreotide

Bottom Line No reduction in mortality Reduction in transfusion requirements by 0.7 units

Prophylactic Antibiotics for Cirrhotics

Bottom Line Reduces mortality (NNT= 22) Prevents infection (NNT = 4)

Restrictive Transfusion Strategy

Bottom Line Restrictive transfusion strategy reduces mortality (NNT = 25) Reduces rebleed (NNT = 17) Reduces adverse reactions (NNT = 13)

Restrictive Transfusion Strategy The Fine Print Study was NOT blinded All participants received one unit of blood before being allocated to either treatment arm All participants received endoscopy within 6 hours of presenting to the ED

Summary  

•  Pa6ents  with  a  GBS  =  0  score  can  be  safely  discharged  from  the  ED  

•  A  restric6ve  transfusion  strategy  and  providing  an6bio6cs  for  cirrho6c  pa6ents  are  both  ED  interven6ons  shown  to  decrease  mortality  

•  PPI  therapy  has  a  limited  role  in  management  in  the  ED