Mgmt of Pts with Ulcer Bleeding (2012) Flashcards
What’s the first step in approaching pt w/ suspected UGIB?
hemodynamic status, risk assessment, resuscitate prn
What are the two common scores to risk stratify?
Rockall score (0-7) Blatchford score (0-23)
What factors make up the Rockall score and what does it predict?
Factors: age, ‘shock’ (SBP <100, HR >100), comorbidities
predicts risk of further bleeding and death in pts hospitalized for UGIB
** this is a pre-endoscopic risk score **
What factors make up the Blatchford score and what does it predict?
Anything interesting (from a disposition perspective) re the Blatchford score?
Factors:
labs (Hgb - M < 13, F < 12; BUN >18.2)
clinical (SBP <110, sex, HR >100, melena, recent syncope, h/o liver dz, cardiac failure)
predicts risk of intervention (transfusion, endoscopic or surgical therapy) and death
If Blatchford score = 0, may consider d/c from ED w/o inpatient endoscopy
what % of UGIB pts have Blatchford = 0 ?
What’s the % of pts w/ Blatchford = 0 that will require intervention?
up to 5-20% of UGIB have Blatchford = 0
<1% chance of requiring intervention
Transfusion goal?
> = 7, or higher if certain comorbidities (cardiac ~ 8)
what else besides transfusion do you need to consider for resucitation?
intubation
goal:
protect airway
prevent aspiration (especially if AMS or ongoing hematemesis)
facilitate safe endoscopy
What are two pre-endoscopic tx options?
erythromycin
gastric lavage
what are the instructions for using pre-endoscopic erythromycin?
why would you use it?
250mg IV given 30 min before EGD
may consider to improve diagnostic yield and to decrease need for repeat EGD (conditional rec; mod qual ev)
However, no improvement in clinical outcomes (transfusion burden, hospital stay, need for surgery)
what is the overall impression of gastric lavage?
don’t do it.
up to 18% of UGIB pts will have clear or bile-stained aspirate
what are the instructions for PPI for acute UGIB?
80mg IV bolus followed by 8mg/hr drip
What are the pros and cons of PPI in acute UGIB?
PROS:
- decrease # of pts w/ high risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot) at index EGD (conditional rec; high qual ev)
- if EGD will be delayed or not done, IV PPI may reduce further rebleeding (conditional rec; mod qual ev)
CONS:
- doesn’t improve risk of death, rebleeding, or surgery
After EGD, what do you do about the PPI?
if no ulcers or erosions on EGD, stop PPI
otherwise. ..
- for pts w/ high risk stigmata of recent hemorrhage (SRH), PPI infusion decreases rebleed rate, need for surgery, and death
- for the oozing subgroup, however, PPI infusion didn’t change risk of rebleeding. may not need PPI infusion for this subgroup
- intermittent PO PPI may be equiv to IV infusion x 72hr
When should you do the EGD?
generally w/n 24hrs of admission (conditional rec; low qual ev)
what defines a high risk pt presenting w/ UGIB?
when should high risk pts have EGD done?
tachycardic, hypoTN, hematemesis, Blatchford >= 12.
For high risk pts, early EGD (w/n 12 hrs of presentation) is a/w better clinical outcomes (fewer transfusions, shorter hospitalization, decreased mortality) (conditional rec; low qual)
Define ulcer
it’s a histologic definition - extension into submucosa or deeper, but endoscopists make dx of ulcer based on their interpretation of the depth visualized
Define erosion
breaks that remain confined to mucosa.
no clinically relevant bleeding occurs from erosions d/t there being no vasculature in the mucosa
What are the 4 high risk stigmata of recent hemorrhage (SRH)?
active spurting bleeding
active oozing bleeding
nonbleeding visible vessel
adherent clot
What are the 2 low risk stigmata of recent hemorrhage (SRH)?
flat pigmented spot
clean base
Forrest classification, prevalence, risk of re-bleed, and risk of death for: active spurting bleeding
tx?
active spurting bleeding
Forrest classification 1A
prevalence 12% (in combo w/ 1B)
risk of re-bleed 55%
risk of death 11%
TX: endoscopic tx, IV PPI x 72hr (strong rec; high qual ev)
Forrest classification, prevalence, risk of re-bleed, and risk of death for: active oozing bleeding
tx?
active oozing bleeding
Forrest classification 1B
prevalence 12% (in combo w/ 1A)
risk of re-bleed 55%
risk of death 11%
TX: endoscopic tx, IV PPI x 72hr (strong rec; high qual ev)
Forrest classification, prevalence, risk of re-bleed, and risk of death for: nonbleeding visible vessel
tx?
nonbleeding visible vessel
Forrest classification 2A
prevalence 8%
risk of re-bleed 43%
risk of death 11%
TX: endoscopic tx, IV PPI x 72hr (strong rec; high qual ev)
Forrest classification, prevalence, risk of re-bleed, and risk of death for: adherent clot
tx?
adherent clot
Forrest classification 2B
prevalence 8%
risk of re-bleed 22%
risk of death 7%
TX: IV PPI x 72hr. Vigorous irrigation of clots is recommended to more accurately assess underlying SRH
may consider endoscopic tx if clot is resistant to vigorous irrigation and pt has features possibly a/w high risk of rebleed (older, comorbidities, already inpt setting at onset of bleed) (conditional rec; mod qual ev)
Forrest classification, prevalence, risk of re-bleed, and risk of death for: flat pigmented spot
tx?
flat pigmented spot
Forrest classification 2C
prevalence 16%
risk of re-bleed 10%
risk of death 3%
TX: no endoscopic tx. switch to PO PPI once daily to heal the ulcer (strong rec; high qual ev)
Forrest classification, prevalence, risk of re-bleed, and risk of death for: clean base
tx?
clean base
Forrest classification 3
prevalence 55%
risk of re-bleed 5%
risk of death 2%
TX: no endoscopic tx. switch to PO PPI once daily to heal the ulcer (strong rec; high qual ev)
what are the categories of endoscopic tx options?
- thermal
- injection
- thrombin (+/- fibrinogen) - not recommended as first line
- clips (pair w/ epinephrine)
what are the types of thermal tx? any special benefits to each of them?
THERMAL OPTIONS:
- bipolar electrocoagulation + (pair w/ epinephrine)
- heater probe +
- monopolar electrocoagulation x
- argon plasma coagulation x
- laser x
+ decreases further bleeding, need for surgery, and mortality (strong rec; high qual ev)
x not recommended as first line tx
what are the types of injection tx?
INJECTION OPTIONS:
- epinephrine
- sclerosants + (absolute ethanol*, polidocanol, ethanolamine)
+ pair w/ epinephrine
* decreases further bleeding, need for surgery, and mortality (strong rec; high qual ev)
how does epinephrine monotherapy compare w/ other endoscopic tx for initial hemostasis? for rebleed risk? for need for surgery?
what are the directions for using epi?
equally effective for achieving initial hemostasis for active bleeding compared to other endoscopic options
HOWEVER, epi mono is inferior for reducing rate of rebleeds and surgery.
*** THEREFORE, if using epi, must combine w/ another modality
use as 1:10,000 or 1:20,000 solution
FOR ACTIVE BLEEDING: inject until bleeding slows or stops
FOR NONBLEEDING SRH: inject in all 4 quadrants next to SRH in ulcer base
TIP:
Preinjecting epi before other tx may help slow or stop bleeding, allowing improved visualization for application of the other tx. Preinjecting epi before clot removal may reduce rate of several bleeding caused by clot removal
what’s a downside of using sclerosant?
high volume of sclerosant may cause tissue necrosis
directions for using absolute alcohol?
use in aliquots of 0.1-0.2mL (max 1-2mL). must pair with epi.
which is superior: thermal tx or sclerosant? why?
thermal tx > sclerosant
thermal tx requires fewer urgent interventions
What patient population might you consider using clips? what’s the theoretical advantage?
theoretical benefit of not inducing tissue injury, so may be preferred for pts on antithrombotics or in those getting re-scoped for rebleeding.
place clips on bleeding site and on either side of the SRH to seal the underlying artery.
directions for using bipolar electrocoagulation
put endoscope tip as close as possible to bleeding ulcer
15W, 8-10 sec applications
apply multiple times in ulcer base on and around SRH until bleeding stops, vessel is flattened, and base is whitened
why do we do PPI infusion for pts w/ high risk SRH?
for pts w/ high risk SRH, PPI infusion decreases rebleed, surgery, and death
How do you disposition pts w/ PUD UGIB?
for pts w/ high risk SRH, generally should be hospitalized x 3 days assuming no rebleeding and no other reason for hospitalization. They may take clear liquids soon after endoscopy (conditional rec; low qual ev)
for pts w/ clean-based ulcer:
regular diet + d/c home assuming hemodynamic and hgb stability (strong rec; mod qual ev)
why do we say pts w/ high risk SRH should be hospitalized x 3 days?
older studies show 95% of rebleeds occur w/n 3 days. More recently, randomized trial showed 24$ of rebleeds were after day 3
why do we recommend clear liquids soon after endoscopy (granted, it’s a conditional rec w/ low qual ev)
since many pts will need urgent interventions for rebleeding, and clear liquids allow sedation/anesthesia w/n 2 hrs after last ingestion
What risk category are Mallory Weiss tears?
Mallory Weiss tears are considered low risk for rebleeding
Long term prevention of recurrent bleeding ulcers:
if H pylori is discovered, what are the tx steps?
tx H pylori, confirm eradication (after at least 1 month after H pylori tx is complete; must d/c PPI at least 2 weeks before testing for eradication), and then can stop antisecretory therapy (unless pt needs NSAIDs or antithrombotics) (strong rec; high qual ev)
Long term prevention of recurrent bleeding ulcers:
if NSAID is the cause, what are the tx steps?
d/c NSAID if possible. If can’t d/c, choose cox2 selective inhibitor at lowest effective dose + daily PPI (strong rec; high qual ev)
Long term prevention of recurrent bleeding ulcers:
if low dose ASA-associated bleeding, what are the tx steps?
re-assess need for aspirin.
if indication is secondary prevention, then resume ASA as soon as bleeding ceases, w/n 7 days + do long term daily PPI
If indication is primary prevention, likely d/c antiplatelet tx (conditional rec; mod qual ev)
Long term prevention of recurrent bleeding ulcers: if idiopathic (non H pylori, non-NSAID) ulcers, what are the tx steps?
tx w/ long term antiulcer tx (e.g. daily PPI) (conditional rec; low qual ev)
