Non- variceal Upper GI bleeding - PowerPoint Presentation

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Non-variceal Upper GI bleeding

Dr. Tarek Mazzawi, MD, PhDDepartment of Internal MedicineFaculty od MedicineAl-Balqa’a Applied University2020

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Agenda

Initial patient evaluationPharmacotherapyEndoscopic therapyArterial embolization and emergency surgeryAnticoagulants

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Hematemesis/Melena- Etiology

Bleeding peptic ulcer 50% (m.c.)Mallory-Weiss tears 10%Esophagitis 10%Esophageal varices <10%

Tumors 5%Hemorrhagic gastritisDieulafoy lesionsAngiodysplasias, Gastric antral

vascular

ectasia

(GAVE

)

Portal Hypertensive gastropathyunknown

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Bleeding peptic ulcer

Mortality: 5-10% (unchanged?/ decreased to 2,5%?) »Laine L. N Engl J Med 2016;374:2367-76Clinical predictors of increased risk

» age >65 years » comorbid illnesses (heart/ lung/ liver) » shock » rebleeding

70

-80% stop spontaneously

 

Risk

for rebleeding greatest first 24 (-48) hours

Risk

assessment/stratification

–

Rockall

score: a pre-endoscopic part as well as the results of endoscopy for

predicting

mortality

–Glasgow

-Blatchford-Scores for pre-endoscopy risk stratification

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A risk score to predict need for treatment for upper GI haemorrhage

Blatchford

O et al. Lancet 2000 Oct14;356(9238):1318-21 Glasgow-Blatchford-Score

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Initial patient evaluation and management

Immediate assessment of hemodynamic status with prompt intravascular volume replacement if hemodynamic instability existsClinical evaluation/ risk stratification (GBS?)– BP, pulse, consciousness, peripheral circulation, respiration, diuresis

, age, comorbid illnesses, anti-coagulation/ NSAID/ SSRI No oral intake/ 2-3 intravenous routes/ appropriate fluid resuscitation/ oxygen Hb and pretransfusion tests

 

Need

for blood transfusions?

– depends on underlying condition and clinical presentation

Multidisciplinary management (gastroenterologist, anesthetist and surgeon)Patient

monitoring at Intensive Care Unit (ICU)

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Blood transfusions

In patients who had restrictive transfusion (transfusion when hemoglobin level drops below 7g/dL) rebleeding was less common (10% vs 16%, p=0·01) and survival was higher at 6 weeks (95% vs 91%, hazard ratio 0·55, 95% CI 0·33–0·92, p=0·02) than in those in the liberal transfusion group

The difference in survival was mainly recorded in patients with liver cirrhosis and PHT  Patients with massive exsanguinating hemorrhage were excluded since red-cell transfusion may be life-saving

Villanueva

C et al. N

Engl

J

Med

2013;368: 11–21

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Treatment overview

Fluid resuscitationBlood transfusion when hemoglobin < 7g/dL – target 7-9 g/dL unless hypoperfusion, CHD or acute hemorrhage Stop

NSAID/APA? Correction of coagulation defects – vit. K antagonists, FFP or intravenous prothrombin complex concentrate – temporarily

withhold direct oral anticoagulants (DOACs) in patients

with

suspected acute

non-

variceal upper GI bleeding (NVUGIH) Erythromycin

250 mg

i.v.

 

Endotracheal

intubation prior to endoscopy if ongoing hematemesis, encephalopathy or agitation

Initiate

high dose intravenous proton pump inhibitors (PPI) in patients presenting with acute NVUGIH awaiting upper endoscopy

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Treatment overview

Pharmacologic management (PPI/ Cyclokapron?) Endoscopy –endoscopic hemostasis with ongoing bleeding or risk of rebleeding Gastroscopy if recurrent bleeding is suspected

– «second-look endoscopy»? Treatment and monitoring of comorbid illnesses (heart failure……) Helicobacter eradication – retesting if negative in the acute setting

–

confirmation of eradication after treatment

 

Ulcer

healing treatment (PPI)

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Pharmacologic treatment

PPI: omeprazole 80 mg i.v. followed by 8 mg/ hour for 72 hours –significant reduction in the need for new endoskopic treatments or surgery –

significant difference in length of bleeding and severity –reduction in mortality (Laine et al.: Clin Gastroenterol

Hepatol

. 2009;7:33-

47)

Schaffalitzky

et al.;

Scand

J

Gastroenterol

1997;32:320-327.

 

effect

of omeprazole on the outcome of

endoscopically

treated bleeding peptic

ulcers

Hasselgren

et al.;

Scand

J

Gastroenterol

1997;32:328-333

continuous

intravenous infusion of

omeprazole

in elderly patients with peptic ulcer bleeding

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Pharmacologic treatment

Fibrinolytic inhibitors (ε-aminocaproic acid): – meta-analysis of 6 randomized studies    –

rebleeding reduced by 20% – surgery reduced by 30% – mortality reduced by 40% (significant)Tranexamic acid (

cyclocaprone

):

 

 

– No evidence to support or refute the use of

tranexamic

acid

for upper

gastrointestinal bleeding

, in terms of mortality,

bleeding

, surgery or

transfusion requirements

–

No significant increase in the number of patients with

thromboembolic

events  

–

Conclusion: At present,

tranexamic

acid cannot be

recommended

for routine

clinical practice

Henry et al

.: Effects of

fibrinolytic

inhibitors on mortality from upper gastrointestinal

haemorrhage

. BMJ 1989;298:1142-1146

Bennet

et al.:

Tranexamic

acid for upper gastrointestinal bleeding. Cochrane Database

Syst

Rev. 2014 Nov 21;(11):CD006640

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Pharmacologic treatment

Prokinetics: 5 RCT (three trials using erythromycin and two using metoclopramide) before endoscopyConclusion – The use of these drugs reduces the need for a second endoscopic examination for diagnosis (OR 0,55, 95% CI 0,32-0,94)– No significant difference in other clinical outcomes

Barkun A et al. Gastrointest Endosc 2010; 72: 1138–45

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Endoscopy

source of bleeding ongoing bleeding risk of rebleeding indication for endoscopic therapy

HP-test

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Endoscopic hemostasis

Risk of rebleeding, need for surgery and mortality significantly reduced hence by 40%, 35% and 50% stops ongoing bleeding in 90-95% Rebleeding

in about 15% of the patients Cook et al. Gastroenterology 1992;102:139-148

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Indications for endoscopic hemostasis

Active spurting and oozing bleeding (Forrest Ia and Ib) U

lcer bed with a non-bleeding ”visible vessel” (Forrest IIa) Adherent clot (Forrest IIb)?

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Risk of rebleeding

High mortality if rebleeding (20-30%) Active bleeding during the endoscopy –risk of rebleeding up to 80-90%

”visible vessel” –risk of rebleeding 40-50% Ulcer location (posterior DU, lesser curvature)size >2 cm

Garcia

-Iglesias P et al.

Aliment

Pharmacol

Ther

. 2011 Oct;34(8):888-900

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Rebleeding

Endoscopy not successful in controlling bleeding in 8-15% Recurrent bleeding after initial endoscopic control occurs in 8-10% of cases Mortality after a surgical salvage 29% in the UK National Audit Rebleedings

from larger ulcers and in shock, not controlled by endoscopy should immediately be remitted to angiographic embolisation or surgery depending on the service available (Lau JY, Sung JJ et al. N Engl J

Med

1999; 340: 751–56

)

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Endoscopic treatment modalities

endoscopic injection therapy bipolar electrocoagulation/ heater probe/ forceps (thermocoagulation) metal clips (hemoclips) and OTSC-clips TC-325 (Hemospray

) argon plasma coagulation (APC) adhesive/glue (N-butyl-2-cyanoacrylate,Histoacryl®) : Gastric

varices

endoscopic

band ligation (EBL) :

Esophageal

varices

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Endoscopic injection therapy

epinephrine solution preferred (no benefit of sclerosants or fibrin glue?) –local tamonade (and possibly vasoconstriction)

epinephrine solution + ”thermotherapy” or clips –epinephrine injection more effective than pharmacotherapy alone –epinephrine monotherapy

inferior to

other

monotherapies

or combination therapies Performance

:

injection

around the bleeding visible vessel

heater

probe or clips directly against the bleeding vessel

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Bipolar electrocoagulation- Gold probe

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Hemoclips

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Endoscopic treatments

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Over the scope clips (OTSC)

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TC-325 Hemospray

Initial hemostasis is 80-90% in active and

oosing bleeding ulcers,

rebleeding

13-25%.

Smith et al. J

Clin

Gastroenterol 2013/2014 HemosprayTM

in patients with acute

PUB

E

Masci

et al. Scan J

Gastroenterol

2014

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Argon plasma coagulation APC

Argon

plasma coagulation therapy for acute non-variceal upper gastrointestinal bleeding Havanond C, Havanond P. Cochrane Database Syst

Rev. 2005 Apr 18;(2):CD003791

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Endoscopic band ligation

Esophageal varices

Dieulafoy lesions Mallory-Weiss tears

Dieulafoy

lesion

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Trans-arterial embolization

Trans-arterial embolization (TAE) versus surgery –TAE successful in 23 of 26 patients (88,5%) –recurrent bleeding in 34,4% vs 12,5% in the surgery group (p=0.01) –more complications in the surgery group, 40,6% vs

67,9% (p=0.01).–no difference in 30-day mortality, 25% vs 30,4% (p=0,77)

T.C.L

Wong et al.

Gastrointest

endoscopy

2011(73);5:900-908

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coil

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Algorithm for endoscopic management of bleeding peptic ulcer

ESGE Guideline.

Endoscopy 2015;47:a1-a46

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Management of bleeding in patients receiving anti-thrombotic treatment

Aspirin, dipyridamole, thienopyridines, glycoprotein IIb/IIIa inhibitors and anticoagulants Anticoagulants targeting factor Xa

/ thrombin such as dabigatran, apixaban and rivaroxaban A clinical dilemma; these patients have increased tendency of thromboembolism because of their underlying cardiovascular occlusive diseases. However, temporary cessation of anti-thrombotic therapy is often necessary to control bleeding or prevent early recurrent bleeding

The

decision to withhold or resume anticoagulants should be multidisciplinary, and should be individualized, balancing thromboembolic risk against risk of recurrent bleeding

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Ulcer bleeding

after aspirin intake Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trail »double blind, randomized study with 156 patients with cardio- or cerebrovascular disease who either got 80 mg aspirin or placebo for 8 weeks immediately after endoscopic therapy

»all got pantoprazole infusion for 72 hours followed by oral treatment »recurrent ulcer bleeding during 30 days follow-up : 10,3% in the aspirin group 5,4

% in the placebo group

»risk of all-case mortality at 8 weeks

:

1,3% in the aspirin group

10,3

% when aspirin was withheld

Sung

JJ et al; Ann Intern

Med

2010 Jan 5;152(1):1-9.

Epub

2009 Nov 30

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ESGE

Guideline. Endoscopy 2015;47:a1-a46

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Conclusions

Assessment of severity of the NVUGIH –need for fluid, blood, plasma and/or platlet replacement Gastroscopy –stabilization of the patient before endoscopy

–endoscopic hemostasis when ongoing bleeding/ ”major stigmatas” ? –injection of adrenalin solution followed by bipolar electrocoagulation or

hemoclips

–

role of

Hemospray? –EBL/ OTSC

Intensive

Care Unit (ICU)

PPI

intraveneously

when peptic ulcer

Arterial

embolization when endoscopic hemostasis is unsuccessful in high risk patients

Surgery

(ligature/ resection)

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References

International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding - Clinical Guidelines »Ann Intern Med. 2010;152:101-113 –Alan N.

Barkun, MD, MSc (Clinical Epidemiology); Marc Bardou, MD, PhD; Ernst J. Kuipers, MD; Joseph Sung, MD; Richard H. Hunt, MD; Myriam Martel, BSc; and Paul Sinclair, MSc, for the International Consensus Upper Gastrointestinal Bleeding Conference Group* Management of Patients With Ulcer Bleeding

–

Loren

Laine

and Dennis M. Jensen.

Am J Gastroenterol 2012; 107:345–360 (published online 7

February

2012)

Challenges

in the management of acute peptic ulcer bleeding

–

James Y W

Lau

, Alan

Barkun

,

Dai-ming

Fan,

Ernst

J

Kuipers

, Yun-

sheng

Yang

, Francis K L

Chan

. Lancet 2013; 381: 2033–43 Endoscopic Management of Acute Peptic Ulcer Bleeding

–

Lu

Y, Chen Y,

Barkun

A.

Gastroenterol

Clin

N Am 43 (2014) 677-705

NVUGIB

: ESGE

Guideline

–

Endoscopy

2015;47:a1-a46

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Thank you for your attention