UGI bleeding of nonvariceal origin in the ICU setting Jouranl of Intensive Care Medicine Vol 16 No'3

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UGI bleeding of nonvariceal origin in the ICU
settingJouranl of Intensive Care MedicineVol
16 No.3 May/June 2001

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Introduction

• Incidence 102-103/ 10? hospitalization
• Mortality rate 5-14
• Multifactors Age, Sepsis, MI, etc.
• Respiratory failure, coagulopathy, sepsis, heart
  failure, renal failure, enteral failure,
  glucocorticoid administration.
• The New England Journal of Medicine
• Volume 330(6),   10 Feb 1994 ,    pp 377-381

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Management prior to endoscopy

• Early endoscopy is important.
• Before endoscopy
• Resuscitation
• Airway protection
• Transfusion (PRBC, FFP)
• Octerotide gt Ranitidine

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Management during endoscopy

• Disease recognition
• Hemostasis

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Disease recongnition
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Peptic ulcer disease

• Duodenitis, gastric erosion or ulcer, duodenal
  erosion or ulcer
• Endoscopic therapy ulcers that associated with
  active bleeding or a nonbleeding visible vessel
• Active bleeding rebleed 4675
• Visible vessel rebleed 5058

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Mallory-Weiss tear

• Cause by a transient increase in the pressure
  gradient between the intrathoracic and the
  intragastic portions of G-E junction, which may
  occur during the act of vomitting or retching
• 0-2 rebleeding rate

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Dieulafoy lesion

• Large, tortuous arteries (1mm) located deep to
  the muscularis propria versus normal vessels in
  the same area that are usually smaller (0.1mm)
• High risk of rebleeding

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SRES

• Stress-ralated erosion syndrome stress
  gastritis
• More shallow, more diffuse, and more numerous and
  higher mortality rate than peptic ulcer disease
• Risk factors prolonged mechanical ventilation
  (gt48hrs) and coagulopathy

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GERD

• Gastroesophageal reflux disease
• Increased transient relaxation of the lower
  esophageal sphincter.
• Same type as those of peptic ulcer disease and
  their risk stratification and approach is the
  same as for peptic ulcer disease.

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Hemostasis
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Hemostasis

• Heat therapy
• Injection therapy
• Combination therapy
• Mechanical device therapy

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Management after endoscopy

• Role of medical therapy after endoscopy
• Role of outpatient management after endoscopy
• Role of endoscopy in patients who rebleed

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Medical therapy

• Eradication of H. pylori is important in the long
  term management of UGI bleeding pts.
• Duodenal ulcer
• Recurrence rate 41?0
• Rebleeding rate 27?0
• Gastric ulcer
• Recurrence rate 62.5?2.4
• Rebleeding rate 37.5?0

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Medical therapy

• Regimen for H. pylory
• Ranitidine (300mg/day) along with triple therapy
  (tetracycline 2g/day, metronidazole 750 mg/day,
  bismuth subsalicylate)
• Ranitidine (300mg/day) with amoxicillin (750mg
  tid) and metronidazole (500mg tid)

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Medical therapy

• Pts without H.pylori infection seem to benefit
  from acid-suppression therapy
• Omeperazole IV (22.5?6.7) or Oral (36.4 ?
  10.9)
• H2 blockers

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Outpatient management

• Baylor scoring system

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Rebleeding management

• Repeat endoscopic therapy should be considered
  prior to surgical intervention

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Prophylaxis

• Correct the pts underlying pathophysiology.
• Reducing intraluminal acid content
• Cimetidine has been shown to decrease the
  incidence of bleeding in this group of pts from
  21 to 2(plt0.002)
• Protecting the gastric mucosal barrier
• Protecting with coating agent such as sucralfate
  has also had demonstrable efficacy.
• Increasing mucosal gastric blood
• Prostaglandin analogues (misoprostol) (?)

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Ranitidine

• 1200 pts on mechanical ventilators were
  randomized in a blinded fashion to a combination
  of sucralfate (1g q6h via NG tube) and
  intravenous placebo or to ranitidine (50mg iv
  q8h). Bleeding occurred in 10 of 596 pts (1.7)
  on ranitidine versus 23 of 604 pts (3.8) on
  sucralfate (plt0.02).

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Ranitidine

• Therefore, at this time, iv ranitidine at a dose
  of 50mg q8h seems to be the standard regimen that
  should be used to prevent the development of SRES
  in high-risk ICU pts.

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