The pharmacological therapy of non-variceal upper gastrointestinal bleeding

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU.

DESIGN

The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development.

INTERVENTIONS

In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements.

MEASUREMENTS AND MAIN RESULTS

We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence.

CONCLUSIONS

Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.

Should Vasoconstrictors be Considered in a Cirrhotic Patient with Acute Non-variceal Upper Gastrointestinal Bleeding?

Varices manifest as a major etiology of upper gastrointestinal bleeding in patients with chronic liver diseases, such as liver cirrhosis and hepatocellular carcinoma. By contrast, non-variceal upper gastrointestinal bleeding is rare. Pharmacological treatment differs between patients with variceal and non-variceal bleeding. Vasoconstrictors are recommended for the treatment of variceal bleeding, rather than non-variceal bleeding. In contrast, pump proton inhibitors are recommended for the treatment of non-variceal bleeding, rather than variceal bleeding. Herein, we present a case with liver cirrhosis and acute upper gastrointestinal bleeding who had a high risk of rebleeding (i.e., Child-Pugh class C, hepatocellular carcinoma, portal vein thrombosis, low albumin, and high international normalized ratio and D-dimer). As the source of bleeding was obscure, only terlipressin without pump proton inhibitors was initially administered. Acute bleeding episode was effectively controlled. After that, an elective endoscopic examination confirmed that the source of bleeding was attributed to peptic ulcer, rather than varices. Based on this preliminary case report, we further discussed the potential role of vasoconstrictors in a patient with cirrhosis with acute non-variceal upper gastrointestinal bleeding.

Use of proton pump inhibitors in the management of gastroesophageal varices: a systematic review

OBJECTIVE

To review the efficacy and safety of proton pump inhibitors (PPIs) in gastroesophageal varices (GEVs).

DATA SOURCES

MEDLINE (1946 to September 2014), EMBASE (1974 to September 2014), International Pharmaceutical Abstracts (1970 to September 2014), Cochrane Central Register of Controlled Trials (1991 to September 2014), Google, and Google Scholar were searched using the following terms: esophageal varices, gastroesophageal varices, variceal hemorrhage, variceal bleeding, banding ligation, endoscopic variceal ligation, sclerotherapy, proton pump inhibitor, PPI, omeprazole, pantoprazole, lansoprazole, dexlansoprazole, rabeprazole, and esomeprazole.

STUDY SELECTION AND DATA EXTRACTION

Published and unpublished studies evaluating the clinical outcomes of PPI use for GEVs were included regardless of study design. Non-English and nonhuman studies were excluded.

DATA SYNTHESIS

Of 1156 studies, 20 were included after assessment. There was wide methodological heterogeneity and moderately high risk of bias among studies. Level I evidence suggests that PPIs reduce esophageal ulcer size post-elective esophageal ligation; the clinical importance of such findings is not known given the self-limiting nature of esophageal ulcer. Available evidence does not support a role of PPIs for long-term prophylaxis of portal hypertension-related bleeding and high-dose infusion for acute management of GEV hemorrhage. Retrospective data demonstrate a potential increase in the incidence of spontaneous bacterial peritonitis in patients with cirrhosis receiving PPIs.

CONCLUSIONS

The best available evidence supports the use of short-course (10 days) PPI post-endoscopic variceal ligation to reduce ulcer size if ulcer healing is a concern. Practices such as high-dose infusion and prolonged use should be discouraged until evidence of benefit becomes available.

State-of-the-art management of acute bleeding peptic ulcer disease

The management of patients with non variceal upper gastrointestinal bleeding has evolved, as have its causes and prognosis, over the past 20 years. The addition of high-quality data coupled to the publication of authoritative national and international guidelines have helped define current-day standards of care. This review highlights the relevant clinical evidence and consensus recommendations that will hopefully result in promoting the effective dissemination and knowledge translation of important information in the management of patients afflicted with this common entity.

Acute gastrointestinal bleeding after percutaneous coronary intervention

Bleeding from the GI tract is a commonly encountered clinical problem after percutaneous coronary intervention. The GI tract is likely to become the most commonly encountered site of bleeding as cardiologists adopt smaller access sheath sizes, percutaneous closure devices and a radial artery approach, further reducing access-site bleeding. To appropriately manage gastrointestinal bleeding in this setting, the clinician must strike a balance between arresting hemorrhage and preventing ischemic coronary complications. To do so, an appreciation of both cardiovascular and gastrointestinal issues is required. This review aims to provide the required knowledge, as well as a series of recommendations from our practice, to assist in the management of this potentially fatal complication.