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