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Management of Acute Bleeding from a Peptic Ulcer

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Epinephrine injection as definitive hemostasis therapy is not recommended The endoscopist should use the most familiar hemostasis technique High-risk Forrest ... – PowerPoint PPT presentation

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Title: Management of Acute Bleeding from a Peptic Ulcer


1
Management of Acute Bleedingfrom a Peptic Ulcer
  • N Engl J Med 2008359928-37

2
Epidemiology
  • 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
  • Peptic ulcer bleeding is seen predominantly among
    the elderly
  • 68 gt 60Y/O and 27 gt80Y/O
  • Mortality associated with peptic ulcer bleeding
    remains high at 5 to 10

3
Management of Acute Bleeding from a Peptic Ulcer,
According to Clinical Status and Endoscopic
Findings
4
The first priority in treatment is
correctingfluid losses and restoring hemodynamic
stability.
5
Initial Management
  • Assess hemodynamic status
  • Tachycardia (pulse, 100 beats per minute)
  • Hypotension (systolic blood pressure, lt100 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 cross-match

6
Initial Management
  • 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

7
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 coffee-ground
    material in NG aspirates are found to have
    high-risk lesions on endoscopy
  • The use of a large-bore OG tube with gastric
    lavage
  • improve visualization of the gastric fundus on
    endoscopy
  • not improve the outcome.
  • No role for occult-blood testing of aspirate

8
Initial Management
  • 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
  • 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
  • No role for H2 blocker

9
Risk-Stratification Tools for Upper
Gastrointestinal Hemorrhage
  • The Rockall score
  • Used clinical and endoscopic criteria
  • The scale ranges from 0 to 11 points, with higher
    scores indicating higher risk.

Blatchford scores from 0 to 23, with higher
scores indicating higher risk
10
Early endoscopy
  • The cornerstone of treatment
  • performed within 24 hours
  • Improve certain outcomes
  • 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 )

11
Forrest classification
Forrest grade IA
Forrest grade IB
Forrest grade IIA
12
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

13
High-risk Forrest grade IA, IB, or IIA
  • 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.

14
Effect of Proton-Pump Inhibition in Peptic-Ulcer
Bleeding
15
Effect of Proton-Pump Inhibition in Peptic-Ulcer
Bleeding
  • 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 proton-pump inhibitors may
    not sustain an intragastric pH of 6 or more.
  • The reduction in mortality appears to occur only
    among patients with high-risk 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

16
High-dose oral PPI
  • The use of high-dose oral PPI in peptic-ulcer
    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

17
Second-look endoscopy
  • 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-by-case
  • if there are clinical signs of recurrent bleeding
  • if there is uncertainty regarding the
    effectiveness of hemostasis during the initial
    treatment.

18
Forrest classification
Forrest grade IIB
19
High-risk Forrest grade IIB
  • 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.

20
Forrest classification
Forrest grade IIC
Forrest grade III
21
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.

22
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23
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 (gt2 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

24
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.

25
Thanks a lot!
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