Bleeding peptic ulcer is a common medical emergency. Today many good studies and evidence based guidelines have provided doctors with a strong evidence based approach to manage this condition. However, how much of daily practice actually follows the evidence? The presentation goes through common scenarios in hospital medicine, and covers the latest evidence through a case based approach.

1. Bleeding Peptic Ulcer Disease
Does Practice Meet Evidence?
Dr Jarrod Lee
Gastroenterologist and Advanced Endoscopist
Mount Elizabeth Novena Hospital
Residents Lecture, Aug 2012

2. Recent International Guidelines
• 2010 International Consensus
• 2011 Asia Pacific Working Group Consensus
• 2012 American College of Gastroenterology
• 2012 American Society of GI Endoscopy
We will focus on inpatient management
2

3. Clinical Scenarios
You Are On Night Call
It‟s Wednesday Midnight
3

4. Case 1
• 50 year male
• Background DM, HPT on meds; follow up GP
• Just admitted for hypoglycemia
• Found to have malena, but otherwise stable
• On arrival in ward:
– Comfortable, parameters stable
– PR: ? Stale malena
– Hb 7.5, no baseline
4

5. What Would You Do?
A. Blood: transfuse vs observe
B. PPI: oral vs IV bolus vs IV infusion
C. NGT: insert or not?
D. Monitoring: GW vs HD
E. Endoscopy: urgent at night vs early next day
5

6. Case 2
• 70 year male
• Background IHD, DM, HPT, AF on warfarin
• Admitted for non-specific giddiness, which was
attributed to anemia
• On arrival in ward:
– Comfortable, parameters stable
– PR: malena
– Hb 7.5 (baseline 12); INR 2.2
6

7. What Would You Do?
A. Blood: transfuse vs observe
B. PPI: oral vs IV bolus vs IV infusion
C. Warfarin: vit K vs FFP vs stop vs continue
D. NGT: insert or not?
E. Monitoring: GW vs HD
F. Endoscopy: urgent at night vs early next day
7

8. Case 3
• 45 year male
• Poorly controlled DM, smoker
• Admitted night before for sepsis ? source
• Informed by staff nurse: large amount fresh
hemetemesis x 1 episode
• HR 100, BP 120/90
• PR: empty rectum
• Hb 13 on admission
8

9. What Would You Do?
A. Blood: transfuse vs observe
B. PPI: oral vs IV bolus vs IV infusion
C. NGT: insert or not?
D. Monitoring: GW vs HD
E. Endoscopy: urgent at night vs early next day
F. Anything else?
9

10. Immediate/ Pre Endoscopy
Management
10

11. Pre Endoscopy Management
• Blood transfusion:
– Should be given if Hb < 7
– Higher threshold if underlying cardiac disease
• Anticoagulants: to reverse or not?
– Must not delay endoscopy
– Correct if supra-therapeutic
– Heater probe treatment safe if INR < 2.5
11

12. Pre Endoscopy Management
• NG Aspirate
– Blood or coffee ground material documents UGIB
– Bloody aspirate increases likelihood of high risk lesion
– 15% of high risk lesions have clear aspirate
• Promotility agents
– Does not consistently improve outcomes
– Not for routine use
– May improve diagnostic yield & decrease need for
repeat endoscopy in selected cases
12

13. Early Endoscopy
• Defined as within 24H
• Improves patient outcomes: decreases length of
stay & decreases surgical intervention
• Indicated for hemetemesis, Hb < 8,
hypovolemia
• May be delayed in selected patients, e.g. AMI,
suspected perforation
• Can facilitate early discharge
13

14. Urgent Endoscopy
• RCTs & observational studies:
– < 6H, 8H or 12H endoscopy has no additional benefit
compared to < 24H
• < 2H: higher risk of endoscopic complications
• Certain subgroups MAY benefit with < 12-13H
– massive fresh hemetemesis, very high risk patients
(Blatchford >11)
• “Night time effect”: night time endoscopy MAY
have higher rate of endoscopic failure
14

15. You Are On Call
It‟s Saturday Midnight
15

16. Case 4
• 60 year woman
• Background DM, HPT, IHD
• Presents with anemia; Hb 6.5
• Urgent OGD
– Posterior wall duodenal ulcer with oozing vessel
– Adrenaline injection applied with „good hemostasis‟
– Post OGD monitored in HD, with IV PPI infusion
• 8H post endoscopy developed hypotension
• Repeat Hb 7.0 despite 2 pints PCT
16

17. What Would You Do Next?
A. Transfuse PCT
B. Insert NGT
C. Refer for urgent endoscopy
D. Refer for endoscopy next AM
E. CT angiogram
F. Refer for radio-embolization
G. Prepare for surgery
17

18. Case 5
• 55 year old male
• IHD s/p PCI (drug eluting stent) 6 mths ago;
on aspirin & clopidogrel
• Presents with malena; Hb 6.0
• 2 pints PCT transfused
• OGD just done, for post-OGD review:
– Antral ulcer with non bleeding visible vessel
– Heater probe applied with „good hemostasis‟
– Post OGD stable; rapid urease positive
18

19. What Would You Do Next?
A. Monitoring: HD vs GW
B. PPI: oral vs IV bolus vs IV infusion
C. Antiplatelets: continue or stop?
D. NBM vs feeds vs diet
E. HP eradication: start or defer?
F. 2nd look OGD cm: arrange or not?
19

20. Case 6
• 65 year old male admitted GM for pneumonia
• IHD, DM, HPT, HPL; on aspirin
• Presents with hemetemesis; Hb 6.0
• Urgent OGD done:
– 2cm antral ulcer with oozing vessel
– Adrenaline injection & 4x hemoclips applied with
„good hemostasis‟
• POT: Back to GW with PCT transfusion, hour
paras, IV PPI infusion, stop ASA, repeat OGD cm
20

21. Do You Agree with POT?
• PCT transfusion
• GW monitoring
• IV PPI infusion
• Stop aspirin
• Repeat OGD cm
– How would you take consent?
21

22. Repeat OGD
• Repeat OGD next AM: clean based ulcer with
2x hemoclips in situ, no blood in stomach
• 2H post OGD, patient complained of chest pain
and found to have NSTEMI
• Subsequently needed CCU monitoring
• PCI/ thrombolysis not performed due to UGIB
• Family very unhappy; takes legal action
against „medical incompetence‟
22

23. Who Is Most Liable?
A. GM ward consultant
B. 1st endoscopist
C. 2nd endoscopist
D. Cardiologist
E. MO taking consent
23

24. Endoscopy & Post Endoscopy
Management
24

25. Endoscopic Hemostasis
• Diagnosis:
– High risk vs low risk lesions
– Clots?
• Hemostasis for high risk lesions:
– Thermocoagulation & mechanical techniques
– Adrenaline alone suboptimal
– Predictors of failure
• Predict rebleed & plan accordingly
25

26. High Risk Stigmata
26

27. Role of PPI
• Pre Endoscopy PPI
– Reduces high risk stigmata & need for endoscopic
hemostasis
– No effect on rebleed, surgery, mortality
– No difference between IV bolus, IV infusion or oral
– Useful if early endoscopy not possible
• Post Endoscopy PPI
– High dose decreases rebleed, surgery & mortality in
high risk lesions after successful endoscopic tx
– Low dose decreases rebleed, not surgery or mortality
27

28. Post Endoscopy
• High risk stigmata
– PPI: IV bolus + infusion x 72H
– Consider HD monitoring
• High risk of rebleed:
– Make definite plans & inform appropriate doctors
• Routine 2nd look endoscopy:
– Recommended against
– May be appropriate if no source found or if initial
therapy inadequate
28

29. Rebleed Management
• Occurs in 10% despite optimum management
• Repeat endoscopy
– Preferred strategy unless predictors of endoscopic
failure on initial endoscopy
• Radiologic embolization
– Alternative to surgery, especially if high surgical risk
– ~ 95% successful
– No difference vs surgery for rebleed or mortality
– Lower morbidity
29

30. General Ward Care
• Timing of diet
• Antiplatelet & anticoagulant therapy
– Restart aspirin ASAP for CVS risk: increases rebleed,
but decreases mortality
– Balance need for clopidogrel or warfarin against
rebleed risk
• Duration of inpatient monitoring: > 72H
– Time needed for high risk lesions to downgrade to
low risk after endoscopic treatment
• Oral PPI after 72H or if low risk lesion
30

31. Discharge Plans
• Antiplatelet treatment required?
– Give ASA with PPI cover
– Clopidogrel: higher rebleeding risk than ASA + PPI
• NSAID required?
– Consider PPI cover or COX 2 or both
• HP eradication:
– Start treatment; test for eradication
– If HP negative at OGD, plan repeat HP testing
• Consider repeat OGD for gastric ulcers
31

32. Preventing Recurrent Ulcer
32

33. Final Words
33

34. Mortality in Bleeding PUD
• Overall mortality 5-10%
• Mortality unchanged over last 10 yrs despite
advances in endoscopy & pharmacology
• Bleeding related causes: 20%
– Failed initial hemostasis: 30%
– Early rebleed: 25%
• Non bleeding related causes: 80%
– Terminal malignancy (30-35%), MOF (25%),
pulmonary causes (25%)
34

35. Survival Pointers
• Immediate emphasis on assessment &
stabilization, not endoscopy
– Always keep NBM first until review or consult
– May allow small clear feeds
– Malena vs iron stool: if Hb trend not convincing, do
PR yourself
• Early endoscopy within 24H
– Consult immediately when case reviewed during
rounds; don‟t wait until rounds over
• When in doubt, always consult expert
35

36. So Does Practice Meet Evidence?
Thank You