Mo1190 - Proton Pump Inhibitors Decrease Upper Gastrointestinal Bleeding in High-Risk Patients on Dual Antiplatelet Therapy

Introduction: Upper gastrointestinal bleeding (UGIB) is a common presentation to the emergency department (ED). Early endoscopy within 24 hours has been shown to reduce re-bleeding rates and lower mortality. However, low-risk patients can often be managed through outpatient follow-up. The aim of this study was to compare the timing and appropriateness of endoscopy and proton pump inhibitor (PPI) use in a tertiary care ED setting for low- and high-risk patients determined using the Glasgow Blatchford Score (GBS). Methods: Retrospective chart review was conducted to examine the management of patients presenting with an UGIB in 2016 to the University of Alberta Hospital ED. TANDEM and Emergency Department Information System (EDIS) databases were used to identify patients using specific ICD-10 codes and the CEDIS presenting complaints of vomiting blood or blood in stool/melena. Patients with GBS 0-3 were categorized as low-risk and those with GBS > 3 were considered high-risk with appropriateness of and time to endoscopy, disposition of patient at 24 hours, and use of PPIs determined for each group. Results: A total of 400 patients were included. A total of 319/400 patients (80%) underwent esophagogastroduodenoscopy (EGD). EGD was performed within 24 hours in 37% of patients (29/78) with GBS 0 to 3 and in 77% (248/322) with GBS greater than 3. Of the remaining high-risk patients, 11% (36/322) underwent EGD after 24 hours and 12% (38/322) did not undergo EGD. The endoscopic diagnoses were peptic ulcer disease (PUD) in 41% of patients (130/319), esophagitis in 18% (56/319), and varices in 14% (45/319). PPIs (data available 375/400) were administered (mainly intravenously) to 93% (279/300) of high-risk and 79% (59/75) of low-risk patients. Data on patient disposition showed 60/322 (19%) high-risk patients were discharged from the ED within 24 hours and only 31/60 (52%) of these underwent EGD before discharge. Of 29 low-risk patients undergoing EGD within 24 hours, 9 (31%) were admitted, 17 (59%) were discharged from ED, and 3 (10%) were kept for observation in the ED greater than 24 hours. Of low-risk patients, 76% (59/78) were discharged from the ED within 24 hours. Conclusion: A majority of patients presenting with UGIB appropriately received endoscopy within 24 hours. 19% of high-risk patients were discharged from the ED. Earlier discharge for low-risk patients can be improved as only 76% of low-risk patients were discharged from the ED within 24 hours. As expected, PPI use was high in these patients.

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Volume of hospital is important for the prognosis of high-risk patients with nonvariceal upper gastrointestinal bleeding (NVUGIB)

Surgical Endoscopy ◽

10.1007/s00464-016-5369-9 ◽

2016 ◽

Vol 31 (8) ◽

pp. 3339-3346

Author(s):

Jin Woo Choi ◽

Seong Woo Jeon ◽

Jung Gu Kwon ◽

Dong Wook Lee ◽

Chang Yoon Ha ◽

...

Keyword(s):

High Risk ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

High Risk Patients ◽

Risk Patients ◽

Upper Gastrointestinal

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Management of acute upper gastrointestinal bleeding

BMJ ◽

10.1136/bmj.l536 ◽

2019 ◽

pp. l536 ◽

Cited By ~ 22

Author(s):

Adrian J Stanley ◽

Loren Laine

Keyword(s):

High Risk ◽

Gastrointestinal Bleeding ◽

Proton Pump Inhibitors ◽

Proton Pump ◽

Variceal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Endoscopic Therapy ◽

Ulcer Bleeding ◽

Vasoactive Drugs ◽

Upper Gastrointestinal

Abstract Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.

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The Role of Rapid Endoscopy for High-Risk Patients with Acute Nonvariceal Upper Gastrointestinal Bleeding

Canadian Journal of Gastroenterology ◽

10.1155/2007/636032 ◽

2007 ◽

Vol 21 (7) ◽

pp. 425-429 ◽

Cited By ~ 36

Author(s):

Laura E Targownik ◽

Sanjay Murthy ◽

Leila Keyvani ◽

Shauna Leeson

Keyword(s):

High Risk ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Tertiary Care ◽

High Risk Patients ◽

Transfusion Requirements ◽

Significant Difference ◽

Risk Patients ◽

Upper Gastrointestinal

BACKGROUND: Performance of endoscopy within 24 h is recommended for patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB). It is unknown whether performing endoscopy early within this 24 h window is beneficial for clinically high-risk patients.METHODS: A retrospective review was performed to identify patients presenting to two tertiary care centres with ANVUGIB and either systolic blood pressure lower than 100 mmHg or heart rate greater than 100 beats/min on presentation between 1999 and 2004. Patients receiving endoscopy within 6 h (rapid endoscopy [RE]) were compared with patients undergoing endoscopy between 6 h and 24 h (early endoscopy [EE]). The primary outcome measure was the development of any adverse bleeding outcome (rebleeding, surgery for control of bleeding, in-hospital mortality or readmission within 30 days for ANVUGIB).RESULTS: There were 169 patients who met the entry criteria (77 RE patients and 92 EE patients). There was no significant difference in the development of any adverse bleeding outcomes between RE and EE patients (25% RE versus 23% EE, difference between groups 2%, 95% CI −9% to 13%). Transfusion requirements and length of hospital stay also did not differ between the comparator groups. RE was not associated with fewer adverse outcomes, even after adjusting for confounders.CONCLUSION: For clinically high-risk ANVUGIB patients, performing endoscopy within 6 h of presentation is no more effective than performing endoscopy between 6 h and 24 h after presentation. The role of RE in high-risk ANVUGIB patients requires further delineation in a prospective fashion.

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Cimetidine and antacid prophylaxis of acute upper gastrointestinal bleeding in high risk patients

The American Journal of Surgery ◽

10.1016/0002-9610(81)90191-4 ◽

1981 ◽

Vol 141 (3) ◽

pp. 339-341 ◽

Cited By ~ 79

Author(s):

Nicola Basso ◽

Maurizio Bagarani ◽

Alberto Materia ◽

Silvana Fiorani ◽

Paolo Lunardi ◽

...

Keyword(s):

High Risk ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

High Risk Patients ◽

Acute Upper Gastrointestinal Bleeding ◽

Risk Patients ◽

Upper Gastrointestinal

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The management of the patient with non-variceal upper gastrointestinal bleeding: from evidence to clinical practice

Italian Journal of Medicine ◽

10.4081/itjm.2016.713 ◽

2016 ◽

Vol 11 ◽

Author(s):

Maddalena Zippi ◽

Mariella Frualdo ◽

Luciano Mucci ◽

Marta Zanon ◽

Chiara Marzano ◽

...

Keyword(s):

High Risk ◽

Gastrointestinal Bleeding ◽

Upper Gastrointestinal Bleeding ◽

Endoscopic Hemostasis ◽

High Dose ◽

Cardiovascular Risks ◽

High Risk Patients ◽

Epinephrine Injection ◽

Risk Patients ◽

Upper Gastrointestinal

A multidisciplinary group of 7 experts developed this update and expansion of the recommendations on the management of acute non-variceal upper gastrointestinal bleeding (NVUGIH) from guidelines published from 2013. The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews. Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermo-coagulation, alone or with epinephrine injection, are effective methods. Second-look endoscopy may be useful in selected high-risk patients, but is not routinely recommended. Intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIH who require a nonsteroidal anti-inflammatory drug, a PPI is preferred to reduce the rebleeding. Patients with NVUGIH needing secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days).

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The Acute Management of Nonvariceal Upper Gastrointestinal Bleeding

Ulcers ◽

10.1155/2012/361425 ◽

2012 ◽

Vol 2012 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Hisham AL Dhahab ◽

Alan Barkun

Keyword(s):

Emergency Department ◽

High Risk ◽

Gastrointestinal Bleeding ◽

Proton Pump Inhibitors ◽

Proton Pump ◽

Upper Gastrointestinal Bleeding ◽

Low Risk ◽

Acute Management ◽

Peptic Ulcers ◽

Upper Gastrointestinal

Background. The mortality from nonvariceal upper gastrointestinal bleeding is still around 5%, despite the increased use of proton-pump inhibitors and the advancement of endoscopic therapeutic modalities. Aim. To review the state-of-the-art management of acute non variceal upper gastrointestinal bleeding from the presentation to the emergency department, risk stratification, endoscopic hemostasis, and postendoscopic consolidation management to reduce the risk of recurrent bleeding from peptic ulcers. Methods. A PubMed search was performed using the following key words acute management, non variceal upper gastrointestinal bleeding, and bleeding peptic ulcers. Results. Risk stratifying patients with acute non variceal upper gastrointestinal bleeding allows the categorization into low risk versus high risk of rebleeding, subsequently safely discharging low risk patients early from the emergency department, while achieving adequate hemostasis in high-risk lesions followed by continuous proton-pump inhibitors for 72 hours. Dual endoscopic therapy still remains the recommended choice in controlling bleeding from peptic ulcers despite the emergence of new endoscopic modalities such as the hemostatic powder. Conclusion. The management of nonvariceal upper gastrointestinal bleeding involves adequate resuscitation, preendoscopic risk assessment, endoscopic hemostasis, and post endoscopic pharmacological and nonpharmacological treatment.

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