Acute upper gastrointestinal bleed - GP Update...Acute upper gastrointestinal bleed A recent BMJ...
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Acute upper gastrointestinal bleed A recent BMJ review considered the diagnosis and management of acute upper GI bleeds, which is most relevant to secondary care, but there is some useful information for primary care about what we should do AFTER an acute bleed (BMJ 2018;363:k4023). Key messages This is a relatively common emergency presentation, affecting 1/1000 people per year – so an average UK surgery will see about 7 cases per year. It has a mortality rate of 10%. In the acute phase, a normal haemoglobin and normal blood pressure do not rule out a substantial bleed. A raised pulse rate is more sensitive. We should refer all patient s with good history. Causes of upper GI bleeds From most to least common: Peptic ulcer. Gastritis/duodenitis. Variceal bleeding. Erosive oesophagitis. Mallory Weiss tear. Tumours. Aorto-enteric fistula/AV malformations. NSAIDs and antiplatelets are common contributory factors. Management after an acute bleed Most patients with a significant bleed will have an endoscopy during their admission and biopsies taken to test for H. Pylori /exclude malignancy in an ulcer. Important issues for primary care are: H. Pylori eradication Treat H.Pylori if found to be positive because eradication reduces the risk of rebleed from 20% to 3%. If testing is performed by biopsy during an acute bleed, a ‘false negative’ may be seen. If the initial test is negative, a stool antigen test should be done at one month. PPI treatment Continue PPIs for 6–8 weeks in H. Pylori-positive ulcers (usually until follow-up endoscopy). Peptic ulcers that have occurred in the absence of H. Pylori infection or NSAIDs have a higher risk of rebleeding, and long- term maintenance dose (15mg lansoprazole or 20mg omeprazole) should be offered. Restarting anti-inflammatories? Avoid NSAIDs if at all possible. If an anti-inflammatory is essential (this will be a small number of patients), ALWAYS use PPI cover. In high-risk individuals (old age or multiple comorbidities), this review suggests considering a COX-2 AND PPI (however, we would need to think about the cardiovascular risk from COX-2s). Restarting antiplatelets Check indication for ongoing treatment – remember, we should not be using aspirin for management of AF or primary prevention of CVD. For secondary prevention of cardiovascular disease, aspirin can usually be restarted by day 3 post-bleed, with continuous lifelong PPI cover (this decision will usually be made in secondary care before discharge). Restarting warfarin/DOACs There is limited evidence regarding this, in patients with AF , a study suggested that even though restarting warfarin after a GI bleed did increase the risk of a further GI bleed, it still overall reduced morbidity and mortality compared with no thromboprophylaxis. There were insufficient people on DOACs to draw firm conclusions about this (BMJ 2015;351:h5876). There is so much we don't know in medicine that could make a difference. Sometimes, it will be dealing with this week's news headlines that will bring patients flocking. Sometimes, with focusing on the big things, the little things can get forgotten. Our weekly Pearls attempt to cut through the clutter and focus on the important issues we shouldn't miss or that make our lives easier!
Transcript of Acute upper gastrointestinal bleed - GP Update...Acute upper gastrointestinal bleed A recent BMJ...
Acute upper gastrointestinal bleedA recent BMJ review considered the diagnosis and management of acute upper GI bleeds, which is most relevant to secondarycare, but there is some useful information for primary care about what we should do AFTER an acute bleed (BMJ 2018;363:k4023).
Key messages
This is a relatively common emergency presentation, affecting 1/1000 people per year – so an average UK surgery will seeabout 7 cases per year.It has a mortality rate of 10%.In the acute phase, a normal haemoglobin and normal blood pressure do not rule out a substantial bleed. A raised pulse rateis more sensitive.We should refer all patients with good history.
Causes of upper GI bleeds
From most to least common:
Peptic ulcer.Gastritis/duodenitis.Variceal bleeding.Erosive oesophagitis.Mallory Weiss tear.Tumours.Aorto-enteric fistula/AV malformations.
NSAIDs and antiplatelets are common contributory factors.
Management after an acute bleed
Most patients with a significant bleed will have an endoscopy during their admission and biopsies taken to test for H. Pylori/excludemalignancy in an ulcer. Important issues for primary care are:
H. Pylori eradication
Treat H.Pylori if found to be positive because eradication reduces the risk of rebleed from 20% to 3%.If testing is performed by biopsy during an acute bleed, a ‘false negative’ may be seen.If the initial test is negative, a stool antigen test should be done at one month.
PPI treatment
Continue PPIs for 6–8 weeks in H. Pylori-positive ulcers (usually until follow-up endoscopy).Peptic ulcers that have occurred in the absence of H. Pylori infection or NSAIDs have a higher risk of rebleeding, and long-term maintenance dose (15mg lansoprazole or 20mg omeprazole) should be offered.
Restarting anti-inflammatories?
Avoid NSAIDs if at all possible.If an anti-inflammatory is essential (this will be a small number of patients), ALWAYS use PPI cover.In high-risk individuals (old age or multiple comorbidities), this review suggests considering a COX-2 AND PPI(however, we would need to think about the cardiovascular risk from COX-2s).
Restarting antiplatelets
Check indication for ongoing treatment – remember, we should not be using aspirin for management of AF or primaryprevention of CVD.For secondary prevention of cardiovascular disease, aspirin can usually be restarted by day 3 post-bleed, with continuouslifelong PPI cover (this decision will usually be made in secondary care before discharge).
Restarting warfarin/DOACs
There is limited evidence regarding this, in patients with AF , a study suggested that even though restarting warfarin after a GIbleed did increase the risk of a further GI bleed, it still overall reduced morbidity and mortality compared with nothromboprophylaxis. There were insufficient people on DOACs to draw firm conclusions about this (BMJ 2015;351:h5876).
There is so much we don't know in medicine that could make a difference. Sometimes, it will be dealing with this week's news headlines that will bringpatients flocking. Sometimes, with focusing on the big things, the little thingscan get forgotten. Our weekly Pearls attempt to cut through the clutter andfocus on the important issues we shouldn't miss or that make our lives easier!
We make every effort to ensure the information in these articles is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, andthis should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular checkdrug doses, side-effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liabilityfor loss of any type caused by reliance on the information in these articles.
Acute upper gastrointestinal bleedingCommon and serious with 10% mortality – refer if good history.Normal blood pressure and haemoglobin are not reassuring in the acute phase.H.Pylori status should be checked and, if positive, treated.Aspirin with a good indication can be restarted at day 3, with lifelong PPI cover.NSAIDs should be avoided if at all possible.
Identify the last 5 cases of upper GI bleed at your practice. Review whether H.Pylori statuswas confirmed. Was a medication review done and PPI prescribed appropriately?
