Modern management of acute non-variceal upper gastrointestinal bleeding

Use of topical mineral powder as monotherapy for treatment of active peptic ulcer bleeding

BACKGROUND AND AIMS

The aim of this study was to evaluate the safety and effectiveness of Hemospray (Cook Medical, Winston-Salem, NC, USA), a hemostatic powder, as monotherapy for active peptic ulcer bleeding.

METHODS

In this prospective, multicenter, single-arm study, patients with Forrest Ia or Ib peptic ulcers underwent endoscopic application of Hemospray as treatment of first intent. Effectiveness endpoints were successful hemostasis at the end of the index endoscopy, recurrent bleeding within 72 hours and from 72 hours to 30 days, adverse events requiring reintervention or resulting in morbidity or mortality, and 30-day mortality.

RESULTS

Hemospray was successfully administered in 98.5% of patients (66/67). Hemostasis was achieved at the index endoscopy in 90.9% of patients (60/66) with Hemospray alone and in an additional 4 patients treated with additional modalities, yielding an overall hemostasis rate of 97.0% (64/66). Rebleeding occurred in 13.3% of patients (8/60), 5 within 72 hours and 3 between 72 hours and 30 days. Two cases of perforation and 2 patient deaths occurred during the study, but none of these cases or any other adverse events were attributed to the use of Hemospray. The rate of early rebleeding was significantly higher in patients with Forrest Ia ulcers compared with patients with Forrest Ib ulcers. Higher rates of early bleeding in patients with Forrest Ia ulcers is consistent with results from studies where Hemospray was used as rescue after failure of conventional methods.

CONCLUSIONS

Hemospray is an effective initial treatment for patients with active peptic ulcer bleeding, but care should be taken to monitor for recurrent bleeding. (Clinical trial registration number: NCT01306864.).

Intravenous Access in Gastrointestinal Hemorrhage: A Multidisciplinary Quality Improvement Initiative Led by Emergency Department Nurses and Internal Medicine Physicians

BACKGROUND

The management of acute gastrointestinal hemorrhage (GIH) is focused on early resuscitation through 2 large-bore intravenous (2LBIV) catheters, although adherence to this recommendation is low.

LOCAL PROBLEM

Of 100 patients hospitalized with GIH in 2017, only 14 received 2LBIV access. The goal of this study was to improve this measure.

METHODS

A multidisciplinary team used the DMAIC (define, measure, analyze, improve, and control) framework to perform a quality improvement initiative.

INTERVENTIONS

The team used quality tools including a stakeholder survey, swimlane diagram, and fishbone diagram. The first intervention involved education of the hospitalists directing admissions, and the second intervention involved education of emergency department (ED) physicians and nurses regarding the importance of 2LBIV placement.

RESULTS

Following the second intervention, there was a substantial increase in 2LBIV placement to 37 of 86 (43%).

CONCLUSIONS

Carefully directed education of ED physicians and nurses with monthly feedback was effective in improving appropriate intravenous placement in patients with GIH.

Need of Emergency Surgery in Elderly Patients with Upper Gastrointestinal Bleeding: Survival Analysis during 2009-2015

BACKGROUND/AIMS

The role of emergency surgery is decreasing in the treatment of patients with upper gastrointestinal bleeding (UGIB). We investigated the need of urgent surgery and outcome of elderly UGIB patients who often have cardiovascular comorbidities with antithrombotic medication.

METHODS

All consecutive adult patients who received emergency treatment for suspected gastrointestinal bleeding between January 2009 and December 2011 were registered in an electronic database (n = 1,643). A total of 569 patients with a first-time UGIB were identified, of whom 282 were ≥70 years old. Age-specific incidence rates, risk factors for bleeding and need of endoscopic or emergency surgery were studied. Long-term mortality was compared to age-adjusted control subjects (n = 569) without bleeding.

RESULTS

The age-specific incidence of UGIB increased from 156 to 401 cases per 100,000 inhabitants from age 60-69 to 80-89 years, respectively. Cardiovascular comorbidities and antithrombotic therapies (acetosalicylic acid 51 vs. 27%; warfarins 25 vs. 11%) related to UGIB were more common in patients over than under 70 years of age (p < 0.0001). Early endoscopic therapy was successful in over 95% of patients, whereas emergency surgery was needed only in 6 (2%) patients ≥70 years old. Hospital mortality (7.8%) was acceptable in these patients, but the 5-year mortality (40%) was significantly higher than in controls (20%, p < 0.001).

CONCLUSION

Today, emergency surgery is seldom needed in the patients with UGIB. In comparison to the age-matched control population, long-term survival was significantly lower after UGIB in the elderly.

Endoscopic application of polysaccharide powder for hemostasis in anticoagulated pigs (with video)

BACKGROUND

Acute GI bleeding remains a clinical problem of daily importance. Increasing numbers of patients with compromised coagulation challenge the established methods of endoscopic hemostasis. Therefore, new powders for the treatment of GI bleeding have been developed.

OBJECTIVE

To clarify the efficacy of a newly available anticoagulant powder in stopping hemorrhage.

DESIGN

A randomized prospective comparative study regarding the potential of an endoscopically applicable polysaccharide powder in pigs receiving antithrombotic medication.

SETTING

A professional veterinary animal laboratory.

PATIENTS

Twenty-two pigs were anticoagulated with heparin (n = 8), aspirin (n = 8), or no antithrombotic medication (n = 6), in a randomized order.

INTERVENTIONS

A bleeding ulcer with continuous bleeding (Forrest I b) was established in the stomach. Endoscopic hemostasis was performed using the powder.

MAIN OUTCOME MEASUREMENTS

Time to hemostasis and the amount of powder used were recorded. Follow-up occurred for 3 days, final hemoglobin measurement, followed by autopsy with control for post-interventional bleeding.

RESULTS

Endoscopic hemostasis was successful in all cases. Post-interventional bleeding was not recorded.

LIMITATIONS

Animal study, artificial superficial bleeding source.

CONCLUSION

Polysaccharide powder is able to stop active bleeding from Forrest I b lesions in pigs receiving antithrombotic therapy.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.