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Literature Summary

Major Literature


  1. Villanueva. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2013;368:11-21
    • In adult patients with UGI bleed, transfusion threshold of 7 vs. 9 g/dl Hgb resulted in higher probability of survival
2013 - Transfusion Strategies for Acute Upper GI Bleeding (NEJM)
  • Methods
    • >18 yrs with hematemsis, melena, or both
      • All pts underwent emergency gastroscopy within 6 hrs
      • 31% had cirrhosis
      • 49% with PUD, 21% with EV
    • Exclusion criteria:  massive exsanguinating bleeding, acute coronary syndrome, symptomatic PVD, CVA/TIA, recent h/o trauma/surgery, or lower GIB
    • RCT, 1 center:  transfusion threshold 7 with goal 7-9 (444 pts, restrictive) vs. transfusion threshold 9 with goal 9-11 (445 pts, liberal)
      • Baseline characteristics were similar
  • Results
    • Transfusion outcome
      • Lower daily hgb until discharge in restrictive, but hgb at 45 days was similar
      • Lower proportion of pts without any transfusion in restrictive (51% vs. 14%)
      • Lower mean units transfused in restrictive (1.5 units vs. 3.7 units)
      • No difference in percentage of pts receiving FFP and platelets
      • No difference in amount of fluids administered
    • Primary outcome
      • Lower all cause mortality at 45 days in restrictive (5% vs. 9%)
        • Lower mortality in pts with cirrhosis w/ Child-Pugh class A or B in restrictive
        • No difference in subgroup mortality for pts with EV or PUD
    • Secondary outcome
      • Lower rate of further bleeding in restrictive (10% vs. 16%), even after adjustment for baseline risk for further bleeding
      • Lower hospital length of stay in restrictive (9.6 days vs. 11.5 days)
      • Lower all cause adverse events in restrictive (40% vs. 48%)
        • Lower transfusion reactions and cardiac complications (mainly pulm edema) in restrictive when analyzed separately
        • No difference in pulmonary complications, AKI, CVA/TIA, or bacterial infection rate
    • Conclusion
      • Restrictive strategy significantly improved outcomes in pts with acute UGIB



2013 - Approach to a Child with UGIB (Indian Journal of Pediatrics)
  • Review paper on UGIB
  • Introduction
    • Definition of UGIB:  bleeding proximal to the ligament of Treitz
    • Hematemesis, melena, and even hematochezia seen
  • Etiology
    • Esophageal varices (EV) one of the most common causes in children
    • Also keep in mind esophagitis, gastritis, ulcers, and "unknown"
    • Less common are Dieulafoy's, AVM, Mallory Weiss, tumors, IBD, vasculitis (HSP)
  • Initial assessment
    • Hemodynamics 
    • Orthostatic BP if able, cap refill, etc.
    • Is it truly blood?
    • Can use Gastroccult test to see if it becomes positive for blood (do not use Hemoccult test...the pH of gastric fluid leads to false results)
    • Is it GI vs pulmonary, oral, or ENT source?
    • Assess for sore throat, epistaxis, cough, etc
    • Is it truly "upper" GI bleed?
    • Use NG lavage to determine if blood coming from stomach and/or above
    • Labs
    • CBC, coags, LFTs, T/S, consider H. pylori testing if indicated
    • Images
    • Abd U/S w/ doppler if clinically indicated
    • Endoscopy for diagnostic and therapeutic measures
  • Management
    • General
    • ABC!
    • Make sure to have at least 2 large bore IVs
    • NG lavage
    • Indicated in all pts, but if pt has a h/o esophageal banding (like in our pt), hold off (per our GI team, but not sure if this is standard of care)
    • I've been taught to use ice water for its vasoconstrictive effect, but no data to back this up
    • Correct coagulopathies and severe thrombocytopenia
    • Variceal bleed
    • Meta-analysis comparing emergency sclerotherapy and pharmacotherapy shows similar efficacy with fewer side effects with the latter (so pharmacotherapy is 1st line therapy)
    • Octreotide 
    • Reduces splanchnic blood flow
    • Controls UGIB in 70% of kids
    • Bolus 1mcg/kg followed by 1mcg/kg/hr titrated up to 4mcg/kg/hr
    • Infusions continued for 24-48hrs after the bleeding has stopped
    • Can cause hyperglycemia as a side effect
    • Vasopressin
    • As effective as octreotide, and its use has largely been replaced by octreotide
    • Endoscopic
    • Perform asap after initial stabilization
    • Variceal ligation, sclerotherapy, argon plasma coagulation
    • Balloon tamponade
    • Blakemore tube can be placed in esophagus (do not use longer than 12hrs in kids)
    • Mucosal bleed (ulcers)
    • PPI
    • <40kg --> 1mg/kg IV qday
    • >40kg --> 20-40mg IV qday
    • BID dosing also commonly used
    • Infusion also can be used, but no evidence that infusion is better than intermittent (per GI team, see the paper below)
    • Endoscopic
    • Epi injection, clips, thermocoagulation
2009 - Continuous Infusion of Pantoprazole with Octreotide Does Not Improve Management of Variceal Hemorrhage (Pharmacotherapy)
  • Methods
    • Retrospective cohort study done in adults to assess the effect of a prolonged continuous infusion of pantoprazole vs. short-term infusion vs. intermittent injection with octreotide
    • 130 adults with variceal bleed (most were esophageal, some were gastric)
    • 53 pts (cohort group):  octreotide + prolonged continuous infusion of PPI (>24 hrs)
    • 77 pts (control group):  octreotide alone vs. octreotide with short-term (<24 hrs) infusion of PPI vs. octreotide with intermittent PPI
  • Results
    • pRBC and platelet transfusion rates not different in cohort vs. control group
    • No difference in mortality, hgb level at end of therapy, rate of recurrent variceal bleed, or need for endoscopic interventions
  • Conclusion
    • Prolonged infusion of PPI with octreotide did not offer clinical benefit compared to octreotide with or without short-term infusion or intermittent injection of PPI
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