Morning Report: 10/14/2014

Medical Therapies for Stable Upper Gastrointestinal Bleeding: Risk, Benefit and Equivocality

Epidemiology

• Incidence: 40-150 per 100,000 per annum, with 450,000 hospitalizations in the USA
• Causes: peptic ulcer (~45%); gastro-duodeno-esophagitis (25%); varicies (~15%) Other (Mallory-Weiss tear, tumor, angiodysplasia, aorto-enteric fistula)

Medical Therapies

Proton Pump Inhibitors (PPIs)

PPIs irreversibly block the hydrogen/potassium ATPase in parietal cells allowing pH to rise which theoretically promotes clot stability and decrease the likelihood of rebleeding

UGIB undifferentiated:

• No reduction in Mortality, need for surgery or rebleeding
• A reduction in the grade of lesion found at time of endoscopic evaluation was found.
  • Systematic review of 4 randomized trials of ~1500 patients (Sreedharan, 2010)

UGIB Peptic Ulcer:

• No reduction in Mortality (OR 1.01, 95%CI 0.74-1.40) or blood transfusion requirements
• Rebleeding was reduced NNT 15
  • Systematic review of 24 randomized trials of 4373 patients (Leontiadis, 2006)

Somatostatin Analogs (Octreotide)

Decreases blood flow in portal circulation thereby decreasing portal pressure

UGIB Variceal

• No reduction in Mortality
• PRBC transfusions reduced by 0.7 U in conjunction with endoscopictreatment (NNT=6)
  • Systematic review of 21 randomized trials of 2588 patients (Gøtzsche, 2008)

Prophylactic Antibiotics

Cirrhotics have impaired immune function and increased translocation of bacteria, therefore prophylactic antibiotics during bleeding may be helpful taking into account that mortality in variceal bleeding is ~ 20% with infection accounting for almost half of all deaths

UGIB Variceal

• Reduction in Mortality NNT = 22
• Reduction in infections NNT = 4 (PNA, UTI, SBP)
  • Systematic review of 12 trials of 1241 patients (Chavez-Tapia, 2010)
    • 1 was placebo controlled and Abx choices varied (gram negative coverage)

References:

• Stanley A, Ashley D, Dalton H et al. Outpatient management of patients with low-risk upper GI haemorrhage: multicentre validation and prospective evaluation. Lancet 2009;373:42-7.
• Lau J, Leung W, Wu J et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. NEJM 2007; 356:1631- 40.
• 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 Jul 7;7:CD005415.
• Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev2006;1:CD002094.
• Somatostatin analogues for acute bleeding oesophageal varices. Gøtzsche PC, Hróbjartsson A. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD000193. Review. PMID: 18677774
• Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD002907. Review. PubMed PMID: 20824832.