ACG issues clinical guidelines on upper GI, ulcer bleeding
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The American College of Gastroenterology published clinical guidelines regarding the management of patients with overt upper gastrointestinal bleeding.
“GI bleeding is the most common GI reason for hospitalization in the U.S. and thus the most common emergency dealt with by gastroenterologists,” Loren A. Laine, MD, FACG, past AGA president, Yale School of Medicine, told Healio. “Establishing up to date, evidence-based guidelines should be very useful in the day-to-day practice of gastroenterologists.”
In a systematic review, Laine and colleagues addressed predefined clinical questions like risk stratification, red blood cell transfusion and pre-endoscopic medical therapy to develop 16 recommendations using the GRADE approach for upper GI bleeding and ulcer bleeding.
Healio presents the following key recommendation from the ACG’s clinical guidelines.
Low-risk patients in the ED may be discharged with outpatient follow-up
Experts suggested very low-risk patients in the ED with upper GI bleeding, defined as a risk assessment score of less than 1% risk for transfusion, hemostatic intervention or death, may be safely discharged with outpatient follow-up.
Without the risk for poor outcomes requiring in-hospital management, this recommendation allows for fewer hospitalizations resulting in a reduction of associated cost.
Restrictive policy of red blood cell transfusion recommended
A restrictive red blood cell transfusion threshold of 7 g/dL in stable patients hospitalized with upper GI bleeding reduced further bleeding and death, experts wrote.
The basis of this recommendation came from a systematic review indicating restrictive policies reduced the number of patients receiving transfusions by 43% without an impact on clinically significant outcomes; it remains unchanged from the 2012 ACG guidelines.
Infusion of erythromycin before endoscopy
Using a prokinetic agent in patients with upper GI bleeding prior to endoscopy will propel blood and clot distally from the upper GI tract leading to improvement in visualization at endoscopy as well as diagnostic yield.
Specifically, experts suggested findings supported an infusion of 250 mg of erythromycin 20 minutes to 90 minutes pre-endoscopy. This may reduce the length of hospitalization and need for repeat endoscopy.
More research needed regarding pre-endoscopic proton pump inhibitor therapy
Available study data did not reveal any benefits of pre-endoscopic PPI therapy for clinical outcomes in patients with upper GI bleeding. Given the unproven possibility that PPIs may benefit select patients for those whom endoscopic therapy in unavailable, experts neither recommend the use of pre-endoscopic PPIs nor recommend against the use of pre-endoscopic PPIs.
Perspective
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John R. Saltzman, MD, FACP, FACG, FASGE, AGAF
We identified important clinical questions in the clinical management of patients with upper GI bleeding and framed each question in the PICO format. This includes the population being studied, the intervention or action studied, the comparator that the intervention is being compared with (such as placebo) and the outcome of interest, usually further bleeding.
All the PICOs then underwent an extensive literature review to identify relevant studies, especially randomized controlled trials (RCTs) and meta-analyses of RCTs. We analyzed all the pertinent studies and graded the quality of the available data based on the GRADE methodology (High, Moderate, Low, Very Low). We then provided a recommendation based on the quality of the evidence that could be strong if we were confident in the quality of the data.
My hope is that physicians will look at these guidelines and realize that the best practice of medicine is evidence-based practice. As you look at guidelines, you will see that they may be different from your practice as there are a lot of subtleties involved, in particular patients and how to best manage them. If you're providing care based on the best quality evidence, your patients will have the best possible outcomes.
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Ari Garber, MD, EdD, MS, EdM
The new ACG guidelines provide a succinct review of the current state of the literature regarding the management of non-variceal upper GI bleeding. Illustrative of the need for evidence-based recommendations to inform practice is the fact that upper GI bleeding remains the most common cause for GI-related hospital admission. While some of the recommendations remain unchanged from the prior iteration in 2012, other statements are informed by additional literature to support contentions and provide stronger levels of evidence.
Beginning with risk stratification and hospital admission, it is recommended that patients with a Glasgow-Blatchford score (GBS) — a scoring system devised to prognosticate who does not warrant intervention — of 0-1 be discharged from the emergency department, as the likelihood of patients necessitating intervention will be on the order of 1 in 100. This is a change from the 2012 recommendation of GBS = 0.
With respect to resuscitation and reflecting randomized controlled trial data from Villanueva and colleagues in The New England Journal of Medicine in 2013, the new guidelines support a restrictive transfusion strategy that promulgates transfusion when the hemoglobin value falls below 7 g/dL in patients without concomitant acute coronary syndrome or pre-existing cardiovascular disease.
In terms of endoscopic timing, and spring boarding off randomized clinical trial data indicating no mortality benefit when endoscopy is performed within 6 hours or between 6 and 24 hours in GBS in 12 or more patients by Lau and colleagues in The New England Journal of Medicine, the panel recommended endoscopic evaluation within 24 hours.
Regarding pharmacologic therapy, PPI therapy outperforms H2-receptor antagonists and has been shown to reduce the risk for rebleeding and mortality. Nonetheless, dosing, frequency (continuous vs. intermittent) and route (IV vs. oral) is nuanced in the updated guidelines to reflect the options of both continuous and intermittent oral as well as IV strategies, expanding routes of administration already used in clinical practice. While data suggesting pre-endoscopic PPI therapy is not robust, the guidelines did not recommend against its use given the possibility that it may reduce the requirement for endoscopic intervention during the procedure itself. When intervention is performed on gastric ulcers specifically, high dose PPI is recommended for 3 days and it is recommended that patients remain on twice daily therapy for a total of 14 days.
Lastly, with respect to endoscopic therapy, much of the consensus recommendations remain unchanged. Gastric ulcers with high-risk stigmata (so called Forrest Classification Ia to IIa lesions) warrant active hemostatic management, whereas ulcers with an adherent clot (Forrest classification IIb) remain controversial. While there are new technological advances on the market, such as hemostatic powders and over-the-scope clips, the mainstay of therapy remains epinephrine injection, cautery and through-the-scope clips with reiteration of the fact that epinephrine should not be used in isolation.
Unless clinical circumstances dictate otherwise, rebleeding after successful endoscopic management should begin with repeat upper endoscopy followed by transcatheter embolization over surgery when the aforementioned fails.
In summary, the new guidelines provide a nice framework for collaborative health care as they pertain to evidenced-based and cost-conscious upper GI bleeding management — from the role the emergency department plays in prognosticating risk and blood bank stewardship to the roles primary care providers and gastroenterologists play in pharmacologic and therapeutic strategies.
References:
- Lau JYW, et al. N Engl J Med. 2020;doi:10.1056/NEJMdo005705.
- Villanueva C, et al. N Engl J Med. 2013;doi:10.1056/NEJMoa1211801.
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