UPPER GI BLEEDING: A BOTTOM UP APPROACH...UPPER GI BLEEDING: A BOTTOM UP APPROACH Sean Caine MD,...
Transcript of UPPER GI BLEEDING: A BOTTOM UP APPROACH...UPPER GI BLEEDING: A BOTTOM UP APPROACH Sean Caine MD,...
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UPPER GI BLEEDING: A BOTTOM UP APPROACH
Sean Caine MD, CCFP-EM UHN Conference
November 3, 2014
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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
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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.
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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
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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
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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.
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Treatment
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Cochrane Database Syst Rev. 2010 Jul 7;(7):CD005415. doi: 10.1002/14651858.CD005415.pub3.
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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
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Cochrane Database Syst Rev. 2008 Jul 16;(3):CD000193. doi: 10.1002/14651858.CD000193.pub3.
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Octreotide
Bottom Line No reduction in mortality Reduction in transfusion requirements by 0.7 units
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Prophylactic Antibiotics for Cirrhotics
Bottom Line Reduces mortality (NNT= 22) Prevents infection (NNT = 4)
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Restrictive Transfusion Strategy
Bottom Line Restrictive transfusion strategy reduces mortality (NNT = 25) Reduces rebleed (NNT = 17) Reduces adverse reactions (NNT = 13)
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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
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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