Transcript Management of Acute Bleeding from a Peptic Ulcer

Management of Acute
Bleeding
from a Peptic Ulcer
N Engl J Med 2008;359:928-37
Epidemiology
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The vast majority of acute episodes of UGI
bleeding (80 to 90%) have nonvariceal causes,
with peptic ulcer accounting for the majority of
lesions.
The annual incidence of bleeding from a peptic
ulcer may be decreasing worldwide ( the
incidence is 60 per 100,000 population)
– an increasing proportion of episodes related to the use
of aspirin and NSAID
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Peptic ulcer bleeding is seen predominantly
among the elderly
– 68% > 60Y/O and 27% >80Y/O
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Mortality associated with peptic ulcer bleeding
remains high at 5 to 10%
Management of Acute
Bleeding from a Peptic Ulcer,
According to Clinical Status
and Endoscopic Findings
The first priority in
treatment is correcting
fluid losses and restoring
hemodynamic stability.
Initial Management
 Assess
hemodynamic status
– Tachycardia (pulse, ≥100 beats per minute)
– Hypotension (systolic blood pressure, <100
mm Hg),
– postural changes (an increase in the pulse of
≥20 beats per minute or a drop in systolic
blood pressure of ≥20 mm Hg on standing)
– Mucous membranes, neck veins, urine output
 Obtain
CBC, electrolytes, BUN/Cr,
PT INR/ APTT, blood type, and crossmatch
Initial Management
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Initiate resuscitation with crystalloid intravenous
fluids with the use of large-bore IV-access
catheters
– two peripheral catheters of 16 to 18 gauge
– a central catheter if peripheral access is not
available
PRBC
– If tachycardia or hypotension is present
– If the hemoglobin level is less than 10 g per
deciliter.
Oxygen
correction of coagulopathy
The insertion of a NG tube
The presence of red blood in the NG
aspirate is an adverse prognostic sign
 15% of patients without bloody or coffeeground material in NG aspirates are found
to have high-risk lesions on endoscopy
 The use of a large-bore OG tube with
gastric lavage
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– improve visualization of the gastric fundus on endoscopy
– not improve the outcome.
 No
role for occult-blood testing of
aspirate
Initial Management
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Consider giving a single 250-mg IV dose
of erythromycin 30 to 60 minutes before
endoscopy
– promote gastric motility and substantially improve
visualization of the gastric mucosa on initial endoscopy.
– not improve the diagnostic yield of endoscopy substantially or
to improve the outcome
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Consider initiating treatment with an IV
PPI (80-mg bolus dose plus continuous
infusion at 8 mg/hr) while awaiting early
endoscopy
– down-staging of endoscopic lesions
– not have an effect on outcomes
– The cost- effectiveness remains controversial
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No role for H2 blocker
Risk-Stratification Tools for Upper
Gastrointestinal Hemorrhage
Blatchford scores from 0 to 23,
with higher scores indicating
higher risk
The Rockall score :
-Used clinical and endoscopic criteria
-The scale ranges from 0 to 11 points, with
higher scores indicating higher risk.
Early endoscopy
The cornerstone of treatment
 performed within 24 hours
 Improve certain outcomes
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– the number of units of blood transfused
– the length of the hospital stay
Determine the cause of bleeding, ascertain
prognosis, and administer endoscopic therapy.
 Treatment recommendations have focused on
the first 72 hours after presentation and
endoscopic evaluation and therapy, since this is
the period when the risk of rebleeding is greatest
(90 %)
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Forrest classification
Forrest grade IA
Forrest grade IB
Forrest grade IIA
High-risk — Forrest grade IA, IB, or IIA
Perform endoscopic hemostasis
– contact thermal therapy
– mechanical therapy ( hemoclips )
– epinephrine injection, followed by contact
thermal therapy or by injection of a second
injectable agent.
 Epinephrine injection as definitive hemostasis
therapy is not recommended
 The endoscopist should use the most familiar
hemostasis technique
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High-risk — Forrest grade IA, IB, or IIA
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Admit the patient to a monitored bed or ICU setting(for
the first 24 hours of what is usually at least a 3-day
hospital stay)
Treat with an IV PPI (80-mg bolus dose plus continuous
infusion at 8 mg per hour) for 72 hours after endoscopic
hemostasis
No role for H2 blocker, somatostatin, or octreotide.
Initiate oral intake of clear liquids 6 hours after
endoscopy in patients with hemodynamic stability
Transition to oral PPI after completion of IV therapy.
Perform testing for Helicobacter pylori; initiate treatment
if the result is positive.
Effect of Proton-Pump Inhibition in
Peptic-Ulcer Bleeding
Effect of Proton-Pump Inhibition in
Peptic-Ulcer Bleeding
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Gastric acid impairs clot formation, promotes platelet disaggregation,
and favors fibrinolysis
Inhibiting gastric acid and raising the intragastric pH to 6 or more and
maintaining it at that level may promote clot stability, thus decreasing the
likelihood of rebleeding.
Although data from clinical trials support the use of a bolus followed by a
continuous infusion of proton-pump inhibitors, recent studies from
North America show that even a high-dose, continuous infusion of protonpump inhibitors may not sustain an intragastric pH of 6 or more.
The reduction in mortality appears to occur only among patients with highrisk stigmata who have first undergone endoscopic therapy, a finding that
supports the use of medical therapy as an adjunct to but not a replacement
for endoscopic hemostasis..
Intravenous bolus loading followed by continuous infusion of proton-pump
inhibitors is more effective than bolus dosing alone in decreasing the rates
of rebleeding and the need for surgery
High-dose oral PPI
 The
use of high-dose oral PPI in pepticulcer bleeding has been shown in Asian
populations reductions
– the risk of rebleeding
– the need for surgery
– the risk of death
 These
results may not be completely
generalizable to North American or
European populations
Second-look endoscopy
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Planned, second-look endoscopy that is performed
within 24 hours after initial endoscopic therapy has not
been recommended.
It provided only a limited reduction in the rate of
rebleeding. (Two meta-analyses)
It may not be cost-effective when medical therapy
leading to profound acid suppression is used.
Repeat endoscopy may be considered on a case-bycase
– if there are clinical signs of recurrent bleeding
– if there is uncertainty regarding the effectiveness of hemostasis
during the initial treatment.
Forrest classification
Forrest grade IIB
High-risk — Forrest grade IIB
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Consider endoscopic removal of adherent clot, followed
by endoscopic hemostasis if underlying active bleeding
or nonbleeding visible vessel is present.
Admit the patient to a monitored bed or ICU setting.
Treat with IV PPI (80-mg bolus dose plus continuous
infusion at 8 mg per hour) for 72 hours after endoscopy,
regardless of whether endoscopic hemostasis was
performed
No role for H2 blocker, somatostatin, or octreotide
Initiate oral intake of clear liquids 6 hours after
endoscopy in patients with hemodynamic stability
Transition to an oral PPI after completion of IV therapy.
Perform testing for H. pylori; initiate treatment if the
result is positive.
Forrest classification
Forrest grade IIC
Forrest grade III
Low-risk — Forrest grade IIC or III
Do not perform endoscopic hemostasis.
 Consider early hospital discharge after
endoscopy if the patient has an otherwise low
clinical risk and safe home environment.
 Treat with an oral PPI.
 Initiate oral intake with a regular diet 6 hours
after endoscopy in patients with hemodynamic
stability.
 Perform testing for H. pylori; initiate treatment if
the result is positive.
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Predictors of failure of endoscopic
treatment
History of peptic ulcer disease
 Previous ulcer bleeding
 The presence of shock at presentation
 Active bleeding during endoscopy
 Large ulcers (>2 cm in diameter)
 Large bleeding vessel (≥2 mm in diameter)
 Ulcers located on the lesser curve of the
stomach or on the posterior or superior
duodenal bulb
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After endoscopy
 If
there is clinical evidence of ulcer
rebleeding, repeat endoscopy with an
attempt at endoscopic hemostasis,obtain
surgical or interventional radiologic
consultation for selected patients.
 For selected patients, discuss the need for
ongoing use of NSAIDs, antiplatelet
agents, and concomitant therapy with a
gastroprotective agent.
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