Management of non-variceal upper GI bleeding (NVUGIB) - An update review of current evidence

Dr Jessie ChanCMCJoint Hospital Surgical Grand Round21 Apr 2012

Major prevalent and clinically significant condition world wide

Important cause of hospitalization and mortality

Clinical and economic burdenOverall incidence decreasesMortality remains unchanged

M.E. van Leerdam. Epidemiology of acute upper gastrointestinal bleeding. Best Practice & Research Clinical Gastroenterology 2008.

Pre-endoscopy proton pump inhibitor (PPI)

Second look endoscopyPost-endoscopy PPIAntiplatelet agentsTransarterial embolization

High-dose PPI infusion accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy

Lau JY et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007.

RCTN = 638

Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.

Meta-analysis

6 RCTsN = 2223

Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.

Meta-analysis

6 RCTsN = 2223

Safe drug profileCost effective

Not used to replace early endoscopy within 24 hours

Joseph JY Sung et al. Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut 2011.

Second-look endoscopy with thermal coagulation showed modest effects in reducing recurrent bleeding

Tsoi KK et al. Second-look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: a meta-analysis . J Gastroenterol Hepatol 2010.

Meta-analysis

5 RCTsN = 998

Chiu PW et al. RCT 2006. N = 201. IV omeprazole with a single endoscopy vs

routine second-look endoscopy without PPI

Recurrent bleeding 8.2% vs 8.7%(RR = 1.07, 95% CI = 0.43–2.66)

High-dose PPI obviated the need for second-look endoscopy as a routine procedure

Not cost effectiveGenerally not recommended as a

routineSelective in high-risk patients

High risk stigmata IV bolus then infusion of high-dose

PPI(e.g. 80mg bolus 8mg/hr infusion)

Raise pH of the stomachStabilize blood clotPrevent further mucosal damage

Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.

Meta-analysis

24 RCTsN = 4373

Reduced rebleeding

Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.

Reduced surgery

Meta-analysis

24 RCTsN = 4373

High-dose oral PPI Javid et al. Am J Med 2001. RCT. N = 166.▪ 40mg Q12H x 5/7

Kaviani MJ et al. Aliment Pharmacol Ther 2003. RCT. N =149.▪ 20mg Q6H x 5/7

Reduced rate of rebleeding, need for surgery and transfusion, shorter hospital stay

Cost effectiveJoseph JY Sung et al. Gut 2011.

Lack of clinical data to provide guidance on a safe period of discontinuation

80% of rebleeding occurred in the first 3 days after index bleeding

Restart aspirin at day 3-5 with stable haemodynamics

Joseph JY Sung et al. Gut 2011.

Similar antiplatelet effect as aspirinResume after 3-5 days

Joseph JY Sung et al. Gut 2011.

No evidence to guide treatment IndividualizedType of stent

Drug-eluting vs bare metal stentDuration of stent

Stent placed within 30 days carries higher risk of thrombosis

Ease of endoscopic haemostasisJoseph JY Sung et al. Gut 2011.

Second attempt at endoscopic therapy Few complications Reduced need of surgery Did not increase mortality

Surgical intervention Better chance to secure haemostasis

Lau JY et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999.

Superselective cannulation +/- embolization of gastroduodenal, left gastric or splenic artery

Guided by clips placed in endoscopy

Wong TC et al. Gastrointest Endosc 2010 .

Gastrointest Endosc 2010 Retrospective

study

No solid evidence to support embolization as an alternative to surgery

Considered as an alternative High surgical risk Expertise available

Joseph JY Sung et al. Gut 2011.

Alan N. Barkun et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of Internal Medicine 2010.

UGIB is a common and important condition

Consider to start PPI early before the first endoscopy

Post-endoscopy high-dose oral PPI may be useful in Asian

Aspirin and clopidogrel may be resumed as early as 3-5 days after the index bleeding

TAE may be considered as an alternative to surgery in recurrent bleeding