Rashid Lui Profile picture
18 Apr, 25 tweets, 15 min read
A #tweetorial on non-variceal upper gastrointestinal bleeding #NVUGIB

And an overview of why we do what we do

To warm up, which of the following is the most common cause of NVUGIB?

#gitwitter #livertwitter #medtwitter #MedEd

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PUD it is...

Btw wt do we mean by "upper"?

This is defined as a bleeding source proximal to the Ligament of Treitz, also known as the suspensory muscle of duodenum, the landmark that separates the duodenum & jejunum Image
3/
Back to PUD, there are actually many well established causes and some associated factors related to its development, the most important being:

💊 Drugs - NSAIDs/aspirin, direct chemical/erosive agents etc
🦠 Bugs - H. pylori
♋ Thugs (if I may) - Neoplasm Image
4/

So what does a patient with UGIB present with?

Listed are some of the commonest presenting symptoms and signs

☕ Isolated coffee ground vomiting is seldom due to UGIB... It could anything... Be wary of IO, sepsis, inferior MIs etc

⚠️ Syncope could be very serious bleeding Image
5/
Syncope or fainting, is such a bad presenting symptom it's included in one of the risk stratification scores known as the Glasgow-Blatchford score (GBS)

Scoring 0⃣ means a low risk of complications and these patients may not need to be admitted

thelancet.com/article/S0140-… Image
6/
A thorough history taking and physical examination is essential:
🧠 mental status
🚫 acute abdomen (ie shouldn't scope and need imaging/surgeon input)
💊 antiplatelets, anticoagulant use
7/
Many things to do before putting a scope in!

⚠️🔤 of resuscitation! Very important

+
DAVID
Diet
Activities
Vitals
Investigations
Drugs: ✅ stuff we give; ❌ stuff we stop
Scoping/Surgery (last but not least!)
⛔ contraindicated in perforation, intestinal obstruction ImageImage
8/
Besides blood taking, 🔬 Ix we routinely request include:
- erect CXR (any free gas, weird funny mediastinal gas)
- ECG (acute coronary syndrome)
&
- #covid19 in this day and age ImageImage
9/
Restrictive transfusion with a Hb >= 7 g/dL is likely sufficient for most hemodynamically stable patients

Subgroup showed that this was better for Child's A/B (postulated that ⬆️splanchnic pressure ➡️ rebleeding, fluid overload, other transfusion Cx)

nejm.org/doi/full/10.10… ImageImage
10/
A meta-analysis (MA) also favoured a restrictive transfusion strategy:
⬇️ Mortality & re-bleeding
↔️ No difference in ischemic events

✅ Transfuse to maintain circulation
❌ Aggressive over-transfusion ImageImage
11/
In REALITY, more evidence is emerging that a restrictive strategy may also be non-inferior for pts at risk for ischemic events, in this case acute myocardial infarction + anemia and 30 day MACE (though the CIs may have included what may be a clinically important harm) Image
12/
❌ Drugs to stop i.e. DAPTs, anticoagulants

Always ⚖️ risks (of thromboembolism) and benefits (easier hemostasis)

Risks of PUD re-bleeding ⬆️ in first 3⃣ days

The 2021 @ESGE_news guidelines in @endoscopyjrnl shared by @drkeithsiau are great!

13/


Time is therapeutic!

In hemodynamically stable patients, withholding DOACs for a suitable duration according to the renal function can definitely help Image
14/
And for a thread discussing the GI safety and efficacy of #DOACs here's the link 👇

In summary: seems that apixaban has a more favourable GI safety profile (no COI)

15/
In hemodynamically unstable cases or uncontrolled bleeding reversal agents may also need to be considered

16/
Finally we arrive at peri-endoscopic mx!

Wt is the role of pre-endoscopy prokinetics?
- A MA in @GIE_Journal showed that erythromycin or metoclopromide given immediately before OGD/EGD ⬇️ the need for repeat endoscopy but not other parameters

ncbi.nlm.nih.gov/books/NBK79206/ Image
17/
How about PPIs?

A landmark trial by Prof Lau @CUHKMedicine showed that pre-emptive PPI infusion:
⬇️ Endoscopic grade of lesions
⬇️ Need for endoscopic treatment

↔️ Similar rates of recurrent bleeding, surgery and 30-day ☠

nejm.org/doi/full/10.10… ImageImage
18/
Moving on to endoscopy, the timing of procedure has been debated for quite a while

A UK audit across 20 centres the median time to endoscopy was 21.2 h (IQR 12-35.7) with early endoscopy (<24 h achieved in ~60% of cases) but is pushing it earlier better? ImageImage
19/
Another RCT by Prof Lau > 500 pts with overt UGIB and a GBS of >= 12 were randomised to urgent (<6h) or early (6-24h) showing that urgent scoping was not ass with ⬇️30day mortality

⚠️Excluded pts who did not stabilize with resuscitation, small no. of variceal bleeds ImageImage
20/
So we finally arrive to the point where we put a scope in

We classify the endoscopic appearance of ulcers by the Forrest classification with great examples by @EndoscopyCampus endoscopy-campus.com/en/classificat…

The rebleeding rates (w/o therapy) are tabulated here Image
21/
Anything above IIa should be treated

We should try removing the clot in IIb and see what it becomes

In a MA, dual endoscopic therapy has largely superceded adrenaline injections alone Image
22/
So what's the role of PPI after endoscopy?

2 RCTs again led by my mentors @CUHKMedicine showed that 72h of PPIs afterwards
⬇️Rebleeding
⬇️Need of Surgery
But didnt show a sig difference for reducing mortality ImageImage
23/
What happens if UGIB recurs?
- repeat endoscopy
- newer modalities
- TAE
- Surgery Image
24/
Excellent reading materials for further interest

@BritSocGastro #AUGIB care bundle
fg.bmj.com/content/11/4/3…

A great updated review in DEN
onlinelibrary.wiley.com/doi/full/10.11… ImageImage
25/
To conclude:
- risk stratification
- Mx: ABC and DAVIDS
- restrictive transfusion unless hemodynamically unstable, ischemic events
- ❌endoscopy if perforation, IO
- tx pre, during and post endoscopy
- balance risk and benefits on resumption of antiplatelets/anticoagulants

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More from @RashidLui

1 May
A #tweetorial on proton pump inhibitors (PPIs)

Just for fun, which drug class is archetypal of a gastroenterologist? 😉

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PPIs would be my pick!

The advent of these potent and effective acid suppression medications led to a paradigm shift in the mx of many GI conditions

The market for PPIs is MASSIVE! Just the projected 5 year growth from 2018 - 2023 estimated to be $3.24 billion! Image
3/
So how do #PPIs work?

A reminder on physiology: this class of drug acts on the gastric parietal cells by irreversibly blocking the hydrogen/potassium adenosine triphosphatase enzyme system (the H+/K+ ATPase, aka the gastric proton pump), hence the elegant name Image
Read 20 tweets
30 Mar
1/
Ever wonder if all #DOACs were created equal? #GITwitter #livertwitter #MedTwitter

Let's start with a poll followed by a #tweetorial on direct oral anticoagulants. First things first, which is your go-to choice of #DOAC ? (COI: none):
2/
These agents work "directly" to anti-coagulate and since they are hardly "new' anymore the term #NOAC has become obsolete. Dabigatran is a direct thrombin inhibitor (factor IIa), whereas the others are factor Xa inhibitors (note the Xa in their names)

3/
In general they share many characteristics such as a quick onset of action, shorter half-lives, potential for drug-drug interactions (CYP3A4 & P-gp) and renal elimination (except apixaban) when compared with warfarin

ncbi.nlm.nih.gov/pmc/articles/P…
Read 18 tweets
14 Mar 20
1/
Sharing of measures observed at my institution in #HongKong currently in place for #COVID19 and some personal practice I have adopted, not exhaustive:

#endoscopy #medtwitter #gitwitter #bettersafethansorry #weareinthistogether #fighting
2/
Departmental
1. Cut all elective cases (only GI bleeds, cholangitis, OJ left; cancer cases reviewed case-by-case)
2. FTOCC +ve should be deferred if possible
3. Full PPE (hair net, face shield/goggles, N95, gowns, gloves etc) as appropriate per local guidance
3/
4. Extended use of N95, but not reuse (changing is protecting patients more than healthcare staff; if you take it off you shouldn't put the same one back on)
5. Scopes done by senior/independent endoscopists; no more training to reduce staff risk exposure and preserve PPE
Read 10 tweets

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