Thursday March 12th, GI bleed

We had a case of low hemoglobin in the setting of melena stools.

Some things to highlight.

We are becoming more excited about restricted transfusion, Villanueva and colleagues published a trial in the NEJM that assessed patients with acute GI bleeds and compared a restricted <70 to a liberal <90. Patients were excluded at the physician's discretion - thus VERY unstable patients who were exsanguinating were likely excluded.

They ended up with 444 patients in the restrictive strategy and 445 in the liberal strategy group

Interestingly, patients with cirrhosis were included

Mortality

Mortality at 45 days was significantly lower in the restrictive-strategy group than in the liberal-strategy group: 5% (23 patients) as compared with 9% (41 patients) (P=0.02)

We use different storing systems (The Rockhall had LHSC) to decide how soon someone should go for scope. Upper endoscopy is always easier to do then lower, and we also know that lower GI bleeds are more likley to stop bleeding on there own.

The basic management of ABCs, cardiac monitor, 2 large bore IVs, always applies!

Classic therapy of PPI 80 mg bolus then 8 mg/hr is standar of care until scope. The increased pH helps platelets clot. We have smaller trials looking at BID PPI therapy instead of an infusion but guidelines have not changed yet. 

After the patient gets an upper endoscopy, we look to see for high risk features, referring to the forrest classification for the risk of rebleed, visible vessel, active bleeding, adherent clot are all features that are high risk. We would generally keep them on PPI and NPO for 48 hours in case they would need to be re-scoped.

Gastric ulcers need to be biopsied, duodenal ulcers - should check for H. Pylori but may not want to biopsy in the setting of fresh bleed, consider empiric therapy, vs follow up with ureas breath test.