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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