dr jessie chan cmc joint hospital surgical grand round 21 apr 2012
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Dr Jessie ChanCMCJoint Hospital Surgical Grand Round21 Apr 2012
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Major prevalent and clinically significant condition world wide
Important cause of hospitalization and mortality
Clinical and economic burdenOverall incidence decreasesMortality remains unchanged
M.E. van Leerdam. Epidemiology of acute upper gastrointestinal bleeding. Best Practice & Research Clinical Gastroenterology 2008.
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Pre-endoscopy proton pump inhibitor (PPI)
Second look endoscopyPost-endoscopy PPIAntiplatelet agentsTransarterial embolization
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High-dose PPI infusion accelerated the resolution of signs of bleeding in ulcers and reduced the need for endoscopic therapy
Lau JY et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007.
RCTN = 638
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Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.
Meta-analysis
6 RCTsN = 2223
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Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review). The Cochrane Library 2012.
Meta-analysis
6 RCTsN = 2223
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Safe drug profileCost effective
Not used to replace early endoscopy within 24 hours
Joseph JY Sung et al. Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut 2011.
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Second-look endoscopy with thermal coagulation showed modest effects in reducing recurrent bleeding
Tsoi KK et al. Second-look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: a meta-analysis . J Gastroenterol Hepatol 2010.
Meta-analysis
5 RCTsN = 998
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Chiu PW et al. RCT 2006. N = 201. IV omeprazole with a single endoscopy
vsroutine second-look endoscopy without PPI
Recurrent bleeding 8.2% vs 8.7%(RR = 1.07, 95% CI = 0.43–2.66)
High-dose PPI obviated the need for second-look endoscopy as a routine procedure
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Not cost effectiveGenerally not recommended as a
routineSelective in high-risk patients
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High risk stigmata IV bolus then infusion of high-dose
PPI(e.g. 80mg bolus 8mg/hr infusion)
Raise pH of the stomachStabilize blood clotPrevent further mucosal damage
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Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.
Meta-analysis
24 RCTsN = 4373
Reduced rebleeding
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Leontiadis et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding (Review). The Cochrane Library 2010.
Reduced surgery
Meta-analysis
24 RCTsN = 4373
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High-dose oral PPI Javid et al. Am J Med 2001. RCT. N = 166.▪ 40mg Q12H x 5/7
Kaviani MJ et al. Aliment Pharmacol Ther 2003. RCT. N =149.▪ 20mg Q6H x 5/7
Reduced rate of rebleeding, need for surgery and transfusion, shorter hospital stay
Cost effectiveJoseph JY Sung et al. Gut 2011.
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Lack of clinical data to provide guidance on a safe period of discontinuation
80% of rebleeding occurred in the first 3 days after index bleeding
Restart aspirin at day 3-5 with stable haemodynamics
Joseph JY Sung et al. Gut 2011.
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Similar antiplatelet effect as aspirinResume after 3-5 days
Joseph JY Sung et al. Gut 2011.
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No evidence to guide treatment IndividualizedType of stent
Drug-eluting vs bare metal stentDuration of stent
Stent placed within 30 days carries higher risk of thrombosis
Ease of endoscopic haemostasis
Joseph JY Sung et al. Gut 2011.
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Second attempt at endoscopic therapy Few complications Reduced need of surgery Did not increase mortality
Surgical intervention Better chance to secure haemostasis
Lau JY et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Med 1999.
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Superselective cannulation +/- embolization of gastroduodenal, left gastric or splenic artery
Guided by clips placed in endoscopy
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Wong TC et al. Gastrointest Endosc 2010 .
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Gastrointest Endosc 2010
Retrospective study
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No solid evidence to support embolization as an alternative to surgery
Considered as an alternative High surgical risk Expertise available
Joseph JY Sung et al. Gut 2011.
Alan N. Barkun et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of Internal Medicine 2010.
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UGIB is a common and important condition
Consider to start PPI early before the first endoscopy
Post-endoscopy high-dose oral PPI may be useful in Asian
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Aspirin and clopidogrel may be resumed as early as 3-5 days after the index bleeding
TAE may be considered as an alternative to surgery in recurrent bleeding
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