Recent guidelines in the management of non-variceal bleeding.
Recent guidelines in the management of non-variceal bleeding
I Dewa Nyoman Wibawa
Div.Gastroentero-hepatology,Dept.of Internal Medicine
UdayanaUniv.;School of Medicine/Sanglah General Hospital.
Extended abstract
In recent years there are several novel developments in the
management of non-variceal bleeding has been growing very rapidly. Some
novel guidelines emerged as the latest guidelines on the management of nonvariceal bleeding.
There are small differences between the new guideline with the
previous one.One of the latest guideline is issued by ESGE 2015.
As we know acute upper gastrointestinal hemorrhage (UGIH) is a
common condition worldwide that has an estimated annual incidence
of40−150 cases per 100 000 populations, frequently leads tohospital
admission, and has significant associated morbidity and mortality, especially
in the elderly. The most common causes of acute UGIH are non-variceal. This
includes peptic ulcers, 28%–59% (duodenal ulcer 17%–37% and gastric ulcer
11%–24%); mucosal erosive disease of the esophagus/stomach/duodenum,
1%–47%; Mallory–Weiss syndrome, 4%–7%; upper GI tract malignancy,2%–
4%; other diagnosis, 2%–7%; or no exact cause identified 7%–25%.
Moreover, in 16%–20% of acute UGIH cases, more than one endoscopic
diagnosis may be identified as the cause of bleeding.1
Based on several guideline available, endoscopic and PPI therapies
are cornerstones to management of non-variceal bleeding. The current
debated issues are; whether early endoscopy improves clinical outcomes and
the paradoxical effect of blood transfusion to recurrent bleeding. The
management of patients on antithrombotic drugs is complex.2
The management of non-variceal bleeding has changed dramatically
over recent decades. Patients with acute non-variceal bleeding should be
managed with early assessment and volume resuscitation. Endoscopic
therapy and pharmacotherapy has become the mainstay in management and
endoscopyshould be performed in all patients within 24 hours of their
presentation. The Glasgow Blatchford score requires validation in different
centers. It is accurate inidentifying those at low risk of requiring intervention.
The risk score is less specific in identifying those who require urgent
endoscopic intervention.During endoscopy, the presence of active bleeding
and a non-bleeding visible vessel mandate endoscopic hemostatic treatment.
There is also evidencethat clots overlying ulcers should be unveiled and
hemostatic treatment offered to underlying stigmata. Injection therapy using
diluted epinephrine aloneis considered inadequate. A second treatment
should be added to induce thrombosis of the bleeding artery. The use of
thermo-coagulation with a thermaldevice or hemo-clips alone or after preinjection with epinephrine is equally efficacious. Second look endoscopy
should be performed in selected high riskor re-bleeding patients. Proton pump
inhibitor (PPI) should administer as an adjunctive therapy. The dose of PPI
use continues to be controversial. Angiographic embolization compares
favorably to surgery as a rescue therapy where endoscopic therapy fails.
Helicobacter pylori should be tested andtreated in the presence of infection. In
those who require aspirin for cardiovascular prophylaxis, aspirin should be
1
resumed early. A low dose PPI should beadded for secondary prophylaxis. In
those who continue to require an analgesic, co-therapy of PPI with traditional
non-steroidal anti-inflammatory agentand the use of COX-II inhibitor alone are
associated with a small risk of recurrent bleeding. A combination of COX-II
inhibitor and PPI is preferred in thosewith very high risk of gastrointestinal
events. In patients on dual antiplatelet agents, PPI appears to reduce
gastrointestinal events without increasingcardiovascular events. 2,3,4
Guideline consensuses for the management of non-variceal bleeding
still present some uncertainties. With regards to initiating blood products,
some evidence suggests that liberal transfusion could exacerbate bleeding
severity, although there is a paucity of large RCTs. Conversely, it is clear that
prompt endoscopy (within 24 hours) improves outcomes, but evidence
suggests that lowering this threshold (e.g. to 12hours) confers no additional
benefit. The useof PPIs, both pre and post endoscopy, for nonvariceal bleeds
is also advocated by professional bodies, with substantial evidence that it
reduces the risk of re-bleeding.5
Asia-Pacific Working Group consensus on non-variceal upper
gastrointestinal bleeding stated that in the way to assess the need for
endoscopic intervention in Asian patients with UGIB, the Blatchford score is
preferred (table 1). When an emergency endoscopy service is available over
weekends and public holidays, no increased mortality is seen at these times.
High-dose oral PPIs may be effective in reducing rebleeding in Asian patients.
Among patients receiving clopidogrel and aspirinas dual treatment,
prophylactic use of a PPI is still recommended to reduce the risk of adverse
gastrointestinal (GI) events. 6
Table 1. Risk stratification – Modified from Glasgow Blatchford risk score (GBS).4
To determine predictors of early rebleeding, defined as rebleeding
before completion of recommended 72 h intravenous proton pump inhibitor
infusion postendoscopic hemostasis, a study was conducted in Canada,
2013. Hematemesis or bright red blood per nasogastric tube aspirate was
identified as the sole independent significant predictor of early rebleeding
versus later among both NVUGIB and, more specifically, patients with peptic
ulcer bleeding (OR 7.94 [95% CI 1.80 to 35.01]; P
I Dewa Nyoman Wibawa
Div.Gastroentero-hepatology,Dept.of Internal Medicine
UdayanaUniv.;School of Medicine/Sanglah General Hospital.
Extended abstract
In recent years there are several novel developments in the
management of non-variceal bleeding has been growing very rapidly. Some
novel guidelines emerged as the latest guidelines on the management of nonvariceal bleeding.
There are small differences between the new guideline with the
previous one.One of the latest guideline is issued by ESGE 2015.
As we know acute upper gastrointestinal hemorrhage (UGIH) is a
common condition worldwide that has an estimated annual incidence
of40−150 cases per 100 000 populations, frequently leads tohospital
admission, and has significant associated morbidity and mortality, especially
in the elderly. The most common causes of acute UGIH are non-variceal. This
includes peptic ulcers, 28%–59% (duodenal ulcer 17%–37% and gastric ulcer
11%–24%); mucosal erosive disease of the esophagus/stomach/duodenum,
1%–47%; Mallory–Weiss syndrome, 4%–7%; upper GI tract malignancy,2%–
4%; other diagnosis, 2%–7%; or no exact cause identified 7%–25%.
Moreover, in 16%–20% of acute UGIH cases, more than one endoscopic
diagnosis may be identified as the cause of bleeding.1
Based on several guideline available, endoscopic and PPI therapies
are cornerstones to management of non-variceal bleeding. The current
debated issues are; whether early endoscopy improves clinical outcomes and
the paradoxical effect of blood transfusion to recurrent bleeding. The
management of patients on antithrombotic drugs is complex.2
The management of non-variceal bleeding has changed dramatically
over recent decades. Patients with acute non-variceal bleeding should be
managed with early assessment and volume resuscitation. Endoscopic
therapy and pharmacotherapy has become the mainstay in management and
endoscopyshould be performed in all patients within 24 hours of their
presentation. The Glasgow Blatchford score requires validation in different
centers. It is accurate inidentifying those at low risk of requiring intervention.
The risk score is less specific in identifying those who require urgent
endoscopic intervention.During endoscopy, the presence of active bleeding
and a non-bleeding visible vessel mandate endoscopic hemostatic treatment.
There is also evidencethat clots overlying ulcers should be unveiled and
hemostatic treatment offered to underlying stigmata. Injection therapy using
diluted epinephrine aloneis considered inadequate. A second treatment
should be added to induce thrombosis of the bleeding artery. The use of
thermo-coagulation with a thermaldevice or hemo-clips alone or after preinjection with epinephrine is equally efficacious. Second look endoscopy
should be performed in selected high riskor re-bleeding patients. Proton pump
inhibitor (PPI) should administer as an adjunctive therapy. The dose of PPI
use continues to be controversial. Angiographic embolization compares
favorably to surgery as a rescue therapy where endoscopic therapy fails.
Helicobacter pylori should be tested andtreated in the presence of infection. In
those who require aspirin for cardiovascular prophylaxis, aspirin should be
1
resumed early. A low dose PPI should beadded for secondary prophylaxis. In
those who continue to require an analgesic, co-therapy of PPI with traditional
non-steroidal anti-inflammatory agentand the use of COX-II inhibitor alone are
associated with a small risk of recurrent bleeding. A combination of COX-II
inhibitor and PPI is preferred in thosewith very high risk of gastrointestinal
events. In patients on dual antiplatelet agents, PPI appears to reduce
gastrointestinal events without increasingcardiovascular events. 2,3,4
Guideline consensuses for the management of non-variceal bleeding
still present some uncertainties. With regards to initiating blood products,
some evidence suggests that liberal transfusion could exacerbate bleeding
severity, although there is a paucity of large RCTs. Conversely, it is clear that
prompt endoscopy (within 24 hours) improves outcomes, but evidence
suggests that lowering this threshold (e.g. to 12hours) confers no additional
benefit. The useof PPIs, both pre and post endoscopy, for nonvariceal bleeds
is also advocated by professional bodies, with substantial evidence that it
reduces the risk of re-bleeding.5
Asia-Pacific Working Group consensus on non-variceal upper
gastrointestinal bleeding stated that in the way to assess the need for
endoscopic intervention in Asian patients with UGIB, the Blatchford score is
preferred (table 1). When an emergency endoscopy service is available over
weekends and public holidays, no increased mortality is seen at these times.
High-dose oral PPIs may be effective in reducing rebleeding in Asian patients.
Among patients receiving clopidogrel and aspirinas dual treatment,
prophylactic use of a PPI is still recommended to reduce the risk of adverse
gastrointestinal (GI) events. 6
Table 1. Risk stratification – Modified from Glasgow Blatchford risk score (GBS).4
To determine predictors of early rebleeding, defined as rebleeding
before completion of recommended 72 h intravenous proton pump inhibitor
infusion postendoscopic hemostasis, a study was conducted in Canada,
2013. Hematemesis or bright red blood per nasogastric tube aspirate was
identified as the sole independent significant predictor of early rebleeding
versus later among both NVUGIB and, more specifically, patients with peptic
ulcer bleeding (OR 7.94 [95% CI 1.80 to 35.01]; P