DPT IV Exam 3 (haney)

upper GI bleeding

source proximal to the ligament of Treitz

variceal upper GI bleeding

complications of end-stage liver disease

non-variceal upper GI bleeding

esophageal

gastric

duodenal

hematemesis

vomiting of blood

coffee ground (digested)

fresh, bright red blood

melena

stool consisting of partially digested blood

black tarry, semi-solid-distinctive odor

more likely with proximal bleeding sites

hematochezia

passage of red or maroon material per rectum

usually represents lower GI source

can occur with a brisk upper GI bleed

occult bleeding

guaiac-positive testing for blood from gastric or fecal sample

overt bleeding

hematemesis

Frank blood or coffee-ground findings in NG aspirate

melena or hematochezia

clinically important bleeding

overt + ≥1 of...

↓ SBP or DBP ≥20 mm Hg within 24 hrs

orthostatic ↑ HR ≥20 bpm and ↓ SBP ≥10 mm Hg

↓ Hgb ≥2 g/dL

≥2 units PRBC

therapeutic endoscopy

vasopressor initiation or increase

important laboratory tests for GI bleeds

CBC with differential

coagulation labs

BUN/SCr ratio

LFTs to detect underlying liver disease

calcium

blood type

risk factors for developing NSAID gastropathy risk factor

age > 65 years

history of PUD or GIB

higher doses and longer duration (> 1 week) of NSAID therapy

concomitant medications such: corticosteroids, antiplatelet agents (including ASA), antithrombotics, selective serotonic reuptake inhibitors, and bisphosphonates

low GI risk based on NSAID risk factors

no risk factors

moderate GI risk based on NSAID risk factors

1 to 2 risk factors

high GI risk based on NSAID risk factors

>2 risk factors

history of complicated ulcer (especially if recent)

cardiovascular high risk factors

requires low dose aspirin

CAD

cerebrovascular accident or PAD

diabetes

high risk of ASCVD (at least 3):

-age > 55

-HTN

-dyslipidemia

-family history of early CVD or stroke (male <55, female <65)

prevention of NSAID gastropathy:

in those without moderate-high risk of CV complications

if there is not a high risk of CV complications:

naproxen or ibuprofen

if there is a high risk of CV complications:

naproxen + PPI

prevention of NSAID gastropathy:

in those with moderate-high risk of CV complications and

if there is not a high risk of CV complications:

celecoxib ± PPI 1 or nonselective NSAID + PPI

if there is a high risk of CV complications:

and NSAID cannot be stopped:*

naproxen + PPI or celecoxib ± PPI

and NSAID can be stopped:*

D/C NSAID

major risk factors for stress related mucosal damage (SRMD)

mechanical vent >48 hrs

intrinsic coagulopathy (plt <50K, INR >1.5, aPTT >2x control)

GI bleeding within 12 months

definite GERD

multiple trauma

head or spinal cord injury

severe burns (>35% BSA)

how can you prevent gastric stress ulcers?

resuscitation to restore mucosal blood flow

early enteral nutrition

pharmacotherapies:

-proton pump inhibitors

-histamine-2-receptor antagonists

-sucralfate

-antacids

H2RAs vs PPIs for stress ulcer prophylaxis

inconsistent results

no mortality benefit with either

available data do not support the routine use of PPIs in most patients who lack compelling indications for PPIs

choice based on convenience of administration, drug interactions, and cost

when administering H2RAs for stress ulcer prophylaxis, what is important to consider?

they must be renally dose adjusted

when administering PPIs for stress ulcer prophylaxis, what is important to consider?

given intermittently

continous infusion not applicable for IV in stress ulcer prophylaxis

possibly increased adverse effects:

pneumonia

C. difficile infection

kidney injury

initial management of nonvariceal upper GI bleed

risk stratify and triage

disposition

pre-endoscopic mangement

upper endoscopy within 24hrs of presentation

post-endoscopic management

risk stratification and triaging for nonvariceal upper GI bleed

determine if:

very low clinical risk

or

not very low clinical risk

*using glasgow blatchford score

disposition for nonvariceal upper GI bleed

outpatient management if no other reason for hospitalization

admit to hospital or observation unit

pre-endoscopic management for nonvariceal upper GI bleed

resuscitation

attend to active comorbidities

possible RBC transfusion

suggest erythromycin

no recommendation for/against PPI

upper endoscopy with 24hrs of presentation for nonvariceal upper GI bleed

low-risk endoscopic findings (e.g., clean-based ulcer, nonbleeding Mallory-Weiss tear, erosions)

non-low-risk endoscopic findings (e.g., bleeding ulcer, varices, neoplasm, Dieulafoy lesion)

post-endoscopic management of nonvariceal upper GI bleed

discharge if vitals and Hgb are stable and no other reason for hospitalization

patient remains in hospital; high-dose PPI x72 hrs

glasgow-blatchford score

systolic blood pressure: less than 109

adds 1 or more point

BUN greater than 18.2

adds 1 or more point

bpm greater than 100, melena, syncope, hepatic, and cardiac failure

add 1 or more point

glasgow-blatchford score of 0-1

low risk for rebleeding of mortality

glasgow-blatchford score of 2 or above

high risk

pearls of resuscitation managment in patients with nonvariceal upper GI bleed

stablize the patient by: protecting the airway, providing supplemental oxygenation, and restoring circulation

identify the source of bleeding

definitive treatment of cause

pearls of circulation management in patients with nonvariceal upper GI bleed

establish IV access by:

2 large bore peripheral catheters

central venous catheter

saphenous vein cut-down

intraosseous

rapid 2-liter bolus of isotonic crystalloid

crossmatch the patient for 2-6 units basde on the rate of active bleeding

indications for PRBC transfusion in patients with nonvariceal upper GI bleed

hemoglobin < 7g/dL

exceptions:

obvious massive blood loss or exsanguination

symptoms due to low hemoglobin/hematocrit

hypotensive patients requiring fluid resuscitation (before 7 g/dL)

pre-existing CVD (<8 g/dL)

indications for platelet transfusion in patients with nonvariceal upper GI bleed

active bleeding and platelets <50K

after 4 units of PRBC

indications for prothrombin complex concentration (PCC) transfusion in patients with nonvariceal upper GI bleed

INR >2

indications for plasma transfusion in patients with nonvariceal upper GI bleed

fibrinogen <100 mg/dL

after 4 units of PRBC

prokinetic agents for patients with nonvariceal upper GI bleed

first attempt removal of substantial quantities of blood, clot, or food in the stomach by nasogastric lavage

these agents propel blood and clot distally from the upper GI tract and improve visualization at endoscopy

erythromycin 250 mg IV over 5-30 min (usually 20-30 min) given 20-90 min before endoscopy

other managements for patients with nonvariceal upper GI bleed

NPO, including meds

hold anticoagulants/antiplatelets (except for ASA for secondary prevention)

supplemental O2

monitor BP, UOP, H&H, platelets

watch for fluid overload

what is the initial diagnostic exam for all patients with presumed UGIB?

endoscopy

preformed within 24 hours

preformed within 12 hours if suscepted variceal bleeding

reverse coagulopathy but do not delay endoscopy

reversal of warfarin

4-factor Prothrombin complex concentrate (PCC)

•not necessary for most patients

•dose is 25-50 units/kg depending on INRot necessary for most patients

consider fresh frozen plasma (FFP) only for life-threatening GIB, supratherapeutic INR substantially exceeding therapeutic range, or need to avoid massive blood transfusion

vitamin K (phytonadione)

•imited value because it doesn't achieve rapid hemostasis

reversal of antiplatelets

platelet transfusions are not recommended unless thrombocytopenic

recommend against holding ASA if being used for secondary cardiovascular prevention

high risk according to forrest classification

class I: acute hemorrhage

-spurting, oozing

class II: recent hemorrhage

-nonbleeding visible vessel

-adherent clot

-flat pigmented spot

low risk according to forrest classification

class III: lesions without active bleeding

-clean ulcer base

-flat spot ulcers

when is therapeutic endoscopy indicated?

high-risk stigmata

-actively bleeding lesions (spurting, oozing)

-non-bleeding visible vessels

when is therapeutic endoscopy not indicated?

ulcers with adherent blood clot resistant to vigorous irrigation

therapeutic endoscopy injection therapy

helps localize the bleeding site

never used as monotherapy

epinephrine injection

therapeutic endoscopy options

thermal coagulation

heater probe**

bipolar electrocoagulation**

sclerosing agents

absolute ethanol**

hemostatic spray

mechanical control

*these may be used alone or in combination with epinephrine

**preferred options

acid suppressive therapy for post endoscopic management

raising intragastric pH to ≥6 may promote clot formation and decrease the risk of rebleeding

H2RAs do not effectively achieve a pH >6

treatment with PPIs for post endoscopic management in those with low risk

those with flat pigmented spots or clean base ulcers

standard PPI therapy (oral, once daily)

treatment with PPIs for post endoscopic management in those with high risk

those with endoscopic hemostatic treatment or with adherent clot

high-dose therapy (≥80 mg daily for at least 3 days)

either continous IV or intermittent PO or IV

then

twice-daily oral PPI on days 4-14, then once daily for at least 2 weeks

secondary prevention therapy for UGIB

continue once daily oral PPI therapy for patients requiring cardiovascular prophylaxis with single- or dual-antiplatelet or anticoagulant therapy (VKA, DOAC) with a duration for as long as on antiplatelet or anticoagulant therapy

esophagitis

-BID for 14 days or once-daily dosing >14 days for severe or complicated cases

-BID >14 days for very severe cases

monitor for C. diff infection, AKI, pneumonia, hypomagnesemia, and osteoporosis-associated fracture

how should anticoagulants or antiplatelets be reinitiated?

reinitiate once risk of CV complication outweighs risk of bleeding

review the need for anticoagulants or antiplatelets

secondary prevention of NSAID gastropathy

COX-2i + PPI (1st line)

COX-2i (2nd line)

nonselective NSAID + PPI (3rd line)

nonselective NSAID + misoprostol 400 mcg BID (4th line)

-avoid ASA for primary prophylaxis

-H. pylori eradication

-add PPI if unable to avoid concomitant SSRI + NSAID

-consider topical NSAID

how should aspirin be reinitiated?

primary prophylaxis: do not restart

secondary prophylaxis: reinitiate with concurrent PPI on the day hemostasis is endoscopically confirmed

how should dual antiplatelet therapy be reinitiated?

data favors adding a PPI to DAPT

ASA + PPI

consider pantoprazole (due to drug interactions)

how should anticoagulants be reinitiated?

benefit of warfarin likely outweighs risk in most patients

patients who were older or with unidentified source were more likely not to resume warfarin1

reinitiating anticoagulation 7-21 days after a GIB may decrease thrombotic and mortality risk while limiting risk of recurrent bleeding1,2

evidence is lacking to guide the resumption of DOACs