Episode 102 GI Bleed Emergencies Part 2

In Part 2 of our two part podcast on GI Bleed Emergencies Anand Swaminathan and Salim Rezaie kick off with a discussion on the evidence for benefit of various medications in ED patients with upper GI bleed. PPIs, somatostatin analogues such as Octreotide, antibiotic prophylaxis and prokinetics have varying degrees of benefit, and we should know which ones to prioritize. We then discuss the usefulness of the Glasgow-Blatchford and Rockall scores for risk stratification and disposition of patient with upper GI bleeds and hit it home with putting it all together in a practical algorithm. Enjoy!

Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Alexander Hart & Shaun Mehta,

Edited by Anton Helman October, 2017

Medications in upper GI bleed emergencies

There is a cocktail that many will learn to give when treating UGIB. Some medications, protocoled though they may be, lack the evidence needed to make them part of standard care. Some we need to give, others are simply nice to give. 

Proton Pump Inhibitors (PPIs) in upper GI bleed emergencies

According to a 2010 Cochrane review, PPIs do not affect clinically important outcomes. There was no change in mortality, re-bleeding, or the need for transfusion or surgical intervention when compared to placebo. There is also little evidence to support the method by which to administer these drugs. Bolus, infusion or both do not alter outcomes [2].

There is some data to suggest that PPIs initiated before endoscopy may reduce high-risk stigmata of bleeding at the time of scope (NNT = 15). Most endoscopists still want PPIs given to ED patients presenting with an UGIB.

Take home message:

  • PPIs should be low priority in your resuscitation
  • Bolus, no infusion – save that line for other more important things
  • If the endoscopist wants a PPI given, give it

Antibiotic prophylaxis in cirrhotic upper GI bleed emergencies

Many cirrhotic UGIB patients do not die from hemorrhage but instead from bacterial infections in subsequent days. It makes sense then, that antibiotics should be part of your initial management of these patients.

According to another 2010 Cochrane review, antibiotic administration was associated with reduced mortality, bacterial infections, re-bleeding events and hospitalization length of stay in cirrhotic patients. The data here is strong, with a NNT of 1 in 22 to prevent death and 1 in 4 to prevent infectious complications [6].

Take home message:

  • Antibiotics such as Ceftriaxone reduce mortality in cirrhotics with upper GI bleed emergencies
  • Make antibiotics a high priority in resuscitation

Somatostatin Analogues: Octreotide

Although a 2008 Cochrane review found no mortality benefit, there is evidence that octreotide may help prevent re-bleeding in both variceal and non-variceal UGIB patients. Octreotide reduces splanchnic blood flow and acid production, so it makes physiologic sense to give it [3].

Take home message:

  • Octreotide, while not life-saving, may prevent rebleeding for both variceal and non-variceal bleeds
  • Octreotide should be a moderate priority in the resuscitation of all UGIB patients regardless of cause

GI motility agents for upper GI bleed emergencies: Erythromycin and Metoclopramide

Administration of IV erythromycin 30 minutes before endoscopy for a bleeding peptic ulcer increases gastric motility and improves visualization of the gastric mucosa at endoscopy. A meta-analysis of 4 trials showed that the use of erythromycin decreased the need for blood transfusion and repeat endoscopy [5].

Metoclopramide is thought to increase GI motility and helps prevent vomiting but studies are small and show no clinical outcome benefit.

 

Order of priority of IV medications in upper GI bleed emergencies

  1. Ceftriaxone 1 g IV for all cirrhotics
  2. Octreotide 50 μg bolus + 50 μg/hr infusion for all UGIB patients
  3. Erythromycin 250mg, 30 minutes prior to endoscopy for suspected peptic ulcer
  4. PPI e.g. Pantaprazole 80 mg IV bolus (no infusion necessary) – once you’ve given everything else, if the endoscopist asks for it

 

NNT Summary for Medications in GI bleed

NNT = 10 for Erythromycin to decrease need for repeat endoscopy

NNT = 0 for PPIs to prevent mortality, surgery and repeat bleeding

NNT = 0 for Octreotide to prevent death or need for transfusion

NNT = 22 for prophylactic antibiotics to prevent death

NNT = 4 for prophylactic antibiotics to prevent infection

 

Risk Stratification and Disposition of GI bleed emergencies

The majority of patients presenting with UGIBs do well, with only 15% requiring intervention. There are several risk stratification scores to help us decide in the ED who is at low risk, but the Glasgow-Blatchford Score (GBS) is the most useful.

Glasgow-Blatchford Score

GI bleed emergenices

 

The Glasgow-Blatchford Score (GBS) is better than another commonly used score, The Rockall Score, in predicting the need for admission, blood transfusion or surgery [10].

GBS is also better than Rockall in predicting patients with UGIB who can be safely discharged. Patients with GBS <3 could be considered for early discharge doubling the number of eligible patients from 15% to 32%.

 

Lactate in risk stratification of GI bleed emergencies

In general, elevated lactate correlates to a worse prognosis in GI bleed as observed in trauma and sepsis patients.

A retrospective 2014 study of 1644 GI patients found that a lactate > 4 mmol/L conferred a 6.4-fold increased odds of in-hospital mortality, and when age, initial hematocrit, and heart rate were controlled, every 1-point increase in lactate conferred a 1.4-fold increase in the odds of mortality [11].

 

Take home stepwise approach to GI bleed emergencies

Gi Bleed Emergencies

Drs. Helman, Swaminathatn, Rezaie and Morgenstern have no conflicts of interest to declare

 

Best Case Ever 51 – Anticoagulants and GI Bleed with Walter Himmel

 

References

  1. Graham DY. Upper Gastrointestinal Bleeding Due to a Peptic Ulcer. N Engl J Med. 2016;375(12):1197-8.
  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 Jul 7;7:CD005415.
  3. Gøtzsche PC. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev 2002;(1):CD000193.
  4. Bernard B, Grange JD, Khac EN, et al. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta- analysis. Hepatology 1999;29(6):1655–61.
  5. Theivanayagam S., Lim RG, Cobell, WJ, Gowda JT, Matteson ML, Choudhary A, Bechtold ML. Administration of erythromycin before endoscopy in upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials. Saudi J Gastroenterol. 2013 Sep-Oct; 19(5):205-10.
  6. Chavez-tapia NC, Barrientos-gutierrez T, Tellez-avila F, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther. 2011;34(5):509-18.
  7. Stanley AJ, Ashley D, Dalton HR, et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicenter validation and prospective evaluation. Lancet 2009;373:42–7.
  8. Rockall TA, Logan RF, Devlin HB, et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet 1996;347:1138–40.
  9. Tham TC, James C, Kelly M. Predicting outcome of acute nonvariceal upper gastrointestinal haemorrhage without endoscopy using the clinical Rockall Score. Postgrad Med J 2006;82:757–9.
  10. Meltzer, AC, etc al. Pre-endoscopic Rockall and Blatchford scores to identify which emergency department patients with suspected gastrointestinal bleed do not need endoscopic hemostasis. J Emerg Med, Vol. 44, No. 6, pp. 1083–1087, 2013.
  11. Shah A, Chisolm-straker M, Alexander A, Rattu M, Dikdan S, Manini AF. Prognostic use of lactate to predict inpatient mortality in acute gastrointestinal hemorrhage. Am J Emerg Med. 2014;32(7):752-5.

 

 

Now Test Your Knowledge:

1. You are treating a cirrhotic patient with an upper GI bleed emergency. Which IV medication would be considered highest priority portending the greatest benefit?

 

a. PPI infusion

b. Ceftriaxone IV

c. PPI bolus

d. Octreotide bolus

 

Correct Answer: B

Antibiotic administration was associated with reduced mortality, bacterial infections, re-bleeding events and hospitalization length of stay in cirrhotic patients in a Cochrane Review. Antibiotics such as Ceftriaxone reduce mortality in cirrhotics with upper GI bleed emergencies, whereas none of the other medications listed have been shown to reduce mortality.

 

2. You are treating a non-cirrhotic patient with a non-variceal upper GI bleed. Which medication has the most benefit?

 

a. Octreotide IV bolus

b. PPI bolus

c. PPI infusion

d. Metoclopramide IV

 

Correct Answer: A

Octreotide, while not life-saving, may prevent rebleeding for both variceal and non-variceal bleeds, while there is little if any clinical outcome benefit for the use of PPIs and Metocopramide.

3. You are seeing a patient with a suspected bleeding peptic ulcer. Which medication should you initiate 30 mins prior to endoscopy to decrease the need for blood transfusion and repeat endoscopy?

 

a. Ceftriaxone

b. Erythromycin

c. Octreotide

d. PPI

Correct Answer: B

Administration of IV erythromycin 30 minutes before endoscopy for a bleeding peptic ulcer increases gastric motility and improves visualization of the gastric mucosa at endoscopy. A meta-analysis showed erythromycin decreased the need for blood transfusion and repeat endoscopy.

4. You are seeing a 70 yo woman in the ED who is a known cirrhotic patient with a variceal bleed. Her vitals are BP: 90/60, HR 101. Initial hemoglobin comes back at 115. What is your predicted disposition for this patient based on the Glasgow-Blatchford score?

 

a. I need more information to make a decision

b. I would discharge the patient home

c. I would admit the patient

d. I would consider the patient for early discharge

Correct Answer: C

According to the Glasgow-Blatchford score, this patient is high risk and does not fulfill criteria for outpatient management.

5. You are seeing a patient with an upper GIB. Which test is the best predictor of mortality?

 

a. Hg

b. BUN

c. Troponin

d. Lactate

Correct Answer: D

A retrospective study found that a lactate > 4 mmol/L conferred a 6.4-fold increased odds of in-hospital mortality. Every 1-point increase in lactate conferred a 1.4-fold increase in the odds of mortality.

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About the Author:

Anton Helman

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

2 Comments

  1. Andrew Allen October 28, 2017 at 1:19 pm - Reply

    I’m confused on the segment regarding cirrhotics in essence being hypercoaguable. I understand that protein c and s and anti thrombin 3 are low balancing coagulopathy with anticoagulants. Warfarin does the same thing with protein c and s so minus antithrombin 3 shouldn’t a warfarin pt and cirrhotic have similar bleeding profiles. Furthermore liver disease has lower fibrinogen further tipping the scale towards hemorrhage. The only difference I think might be lower levels of plasminogen in cirrhosis. Over all I did not fully understand why a cirrhotic learns towards hypercoaguable given mirrored findings with regard to protein c and s in both liver dz and warfarin. Again is lower plasminogen the rationale for all of this in liver disease. I remain confused

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