Morning Report: 3/6/2014 - The Original Kings of County

Thanks to Dr. Basile for presenting today’s Morning Report!

Case: 74 yo female with pmh of HTN and arthritis presents with 3-4 days of lightheadedness and weakness. Pt also reports intermittent epigastric abdominal pain two days prior to presentation. Pt has also been taking naproxen for two weeks.

BP: 171/97, HR: 84, RR: 19, O2 sat: 100%, T: 98.4.

Rectal: guiac positive, maroon/black color stool

Significant Labs: Hgb/Hct 7.4/23.5 which was significant decrease from one year ago when Hgb was 12.2.

What is your plan besides type and cross, admission, GI consult, and blood transfusion?

Is there a benefit to initiating proton pump inhibitor therapy (or PPI drip) prior to endoscopy in a patient with a presumed upper GI bleed and how fast does endoscopy need to be done?

UGI Bleeding:

– Significant mortality rate between 7-14 %

– Common: annual incidence of Upper GI bleed is between 48-165 per 100,000 leading to over 300,000 hospitalizations and 2.5 billion dollars

– Mortality is associated with rebleeding

– Incidence of rebleeding ranges from 5-20%

– Predictors of poor prognosis are age over 65, shock, poor overall health, comorbid conditions, low initial Hgb/Hct, active bleeding (red blood per rectum or hematemesis), sepsis, and elevated creatinine or ast/alt

– Most common cause of Upper GI bleeding is peptic ulcer bleeding which makes up 31-67% of all cases

Management:

– ABCs

– Blood transfusion prn

– Medical therapy (PPI)

– Endoscopy

PPI:

– Gastric acid is thought to inhibit cessation of bleeding via two mechanisms

inhibition of clot formation
persistent tissue damage

– PPIs decrease gastric acid

– Guidelines from a consensus statement do recommend the use of empiric treatment with PPIs in patients with Upper GI Bleeding waiting for endoscopy

– A recent Cochrane review looked at the question of whether there was a benefit of PPI treatment being initiated prior to endoscopic diagnosis in upper GI bleeding

PPI did not have a significant effect on 30 day mortality, rebleeding, the need for blood transfusion, presence of blood in the stomach, or the need for surgery
PPIs were found to significantly reduce the proportion of patients with stigmata of recent hemorrhage (active spurting or oozing, non bleeding visible vessel, or adherent clot)
Use of PPIs prior to endoscopy also lead to a significantly decreased need for endoscopic haemostatic treatment during the endoscopy

– There is no consensus on the type or dose of pre-endoscopic PPI that should be used

– It is recommended that patients with high risk stigmata seen on endoscopy (active bleeding or a visible vessel) or after successful endoscopic hemostasis should be treated with high dose continuous IV PPI therapy

– NO EVIDENCE THAT PPI DRIP PRIOR TO ENDOSCOPY IS BENEFICIAL/NECESSARY

– PPI therapy POST endoscopy has been associated with a decrease in recurrent bleeding, need for blood transfusion, need for surgery, and hospital length of stay

Endoscopy:

– Debate in the literature regarding the optimal timing for endoscopy.

– Early endoscopy can lead to early hemostasis, but also carries the risk of potential aspiration of blood and oxygen desaturations in patients who are unstable

– Very early endoscopy (less than 6 or less than 12 hours) has not been shown to reduce the bleeding, the need for surgery, or mortality compared to later endoscopy (within 24 hours)

– Currently recommended that endoscopy be done WITHIN 24 hours of presentation because it has been shown to lead to a reduced length of stay and improve outcomes

References:

1) Trawick EP, Yachimski PS. Management of non-variceal upper gastrointestinal tract hemorrhage: controversies and areas of uncertainty. World J Gastroenterol. 2012 Mar 21;18(11):1159-65.

2) Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010:CD005415.

3) Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol. 2012 Mar 21;18(11):1202-7.

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital