Acute upper GI bleeding: anything new?

 

This topic was recently reviewed in the article linked here:

Acute upper gastrointestinal bleeding: state of the art review

Some key points follow.

Prevention

In critical illness, PPI therapy is recommended in selected high-risk patients. 

Determinants of high risk were not specified in the review.

The review recommends outpatient PPI therapy for “high risk“ patients on DAP

or oral anticoagulants without specifying the risk factors.

Acute management

For patients with hemodynamic instability, a 500 mL crystalloid bolus is recommended

for initial volume management. Specific recommendations for continued volume 

management were not given, but it can be implied that subsequent bolus therapies 

and running IV fluids would be based on the patient's response and clinical judgment.

Transfusion threshold

A hemoglobin target of 7 g/dl is recommended as the threshold in general. A higher 

threshold may be considered in ischemic heart disease or if there is active 

exsanguination. The particulars regarding those conditions were not given.

New developments in risk assessment

Artificial intelligence based risk prediction and blood sensing capsules are promising 

but not ready for prime time.

Management of antithrombotics

For patients on dual antiplatelet therapy with acute bleeding, the review recommends

temporary stoppage, except for continuation of aspirin when possible if the DAP was

given for maintenance of stent patency. In such cases, the other agent should be restarted

within 5 days if bleeding is controlled.

For patients on systemic anticoagulation, mere stoppage is indicated if there is

hemodynamic stability. If unstable, reversal is indicated.

Idarucizumab is recommended for reversal of dabigatran. For patients on anti-X a 

agents, andexanet or four factor PCC  is recommended.

Restart of systemic anticoagulants in patients with low thrombotic risk is recommended

at 7 days or later.  For high thrombotic risk, restart is recommended within 3 days, 

with bridging where applicable.

Tranexamic acid is generally not recommended.

Proton pump inhibitors

The literature regarding their use is somewhat controversial, but the review 

acknowledges the common practice of giving an 80 mg bolus of pantoprazole followed

by an 8 mg per hour drip or an 80 mg bolus followed by 40 mg IV BID thereafter

EGD

For all GI bleeds, at 12 to 24 hours. If variceal is suspected, less than or equal to 12 

hours.

Endotrachael intubation for EGD is not routinely recommended. The recommendation for

intubation applies only to patients who are obtunded, have massive hematimesis, or

evidence of poor airway protection.

In cases of rebleeding the following sequence is recommended: repeat 

endoscopy ---> IR embolizqation ---> surgery.

Special considerations in variceal bleeding:

In general, many of the recommendations for non-variceal acute upper GI bleeding apply, 

but there are some special considerations. The following points regarding variceal

bleeding are drawn from guidelines published in Hepatology linked here.

AASLD Practice Guidance on risk stratification and management of portal hypertension

and varices in cirrhosis

Cirrhotic patients with upper GI bleeding should be treated as variceal until proven

otherwise.

Such patients should be started on vasoactive therapy (eg octreotide) and intravenous 

antibiotic therapy immediately. Antibiotic therapy duration is to discharge or five days, 

whichever is shorter.

RBC transfusion thresholds are similar to the recommendations above for GI bleeding

in general.

EGD within 12 hours is recommended for suspected variceal bleeding.

Early TIPS (same admission) is recommended in the following patients: 

Those with a CTP score greater than 7 plus active bleeding at EGD.

Any patient with CTP greater than or equal to 10 regardless of whether active 

bleeding is present.

Any patient who rebleeds or whose bleeding cannot be controlled endoscopically

If TIPS is not done, non-selective beta blocker administration is recommended.

Feeding is recommended once bleeding is controlled. The presence of varices or 

bands is not a contraindication to feeding per os or via tube if indicated.

Dealing with coagulation parameters in cirrhosis:

The review, the guideline, and Up to Date are vague in this area. These

recommendations are best summarized as follows:

Generally, coagulation parameters need not (and should not)  be corrected.  

However, room is left for clinical judgment.  (If it is a nonvariceal bleed, 

Up to date recommends a platelet transfusion target of 50K).

Cryoprecipitate, either empirically (in active bleeding)  or if fibrinogen is below 

120K is stated to be “reasonable“  by the Up to Date authors.  (The Up to Date 

article is vague as to whether this recommendation applies to variceal bleeding, 

non-variceal bleeding or both).

Thus, there is considerable room for clinical judgment. The underlying rationale

for the recommendations regarding coagulation management in cirrhosis is as follows:

Portal pressure, not hemostasis, is the principal driver of bleeding.

Due to the ”rebalanced hemostasis” characteristic of cirrhosis, coagulation parameters 

are not predictive of bleeding risk.

The volume load of FFP needed to ”correct” an elevated INR will likely increase

portal pressure, thus aggravating bleeding.

There's insufficient evidence regarding 4 factor PCC in cirrhotic bleeding. In 

general, it is not recommended unless for anticoagulant reversal.