Episode 102 GI Bleed Emergencies Part 2

In Part 2 of our two part podcast on GI Bleed Emergencies Anand Swaminathan and Salim Rezaie kick off with a discussion on the evidence for benefit of various medications in ED patients with upper GI bleed. PPIs, somatostatin analogues such as Octreotide, antibiotic prophylaxis and prokinetics have varying degrees of benefit, and we should know which ones to prioritize. We then discuss the usefulness of the Glasgow-Blatchford and Rockall scores for risk stratification and disposition of patient with upper GI bleeds and hit it home with putting it all together in a practical algorithm. Enjoy! Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Alexander Hart & Shaun Mehta, Edited by Anton Helman October, 2017 Cite this podcast as: Swaminathan, A, Rezaie, S, Helman, A. GI Bleed Emergencies Part 2. Emergency Medicine Cases. October, 2017. https://emergencymedicinecases.com/gi-bleed-emergencies-part-2/. Accessed [date]. Go to part 1 of this 2-part podcast on GI bleed emergencies Medications in upper GI bleed emergencies There is a cocktail that many will learn to give when treating UGIB. Some medications, protocoled though they may be, lack the evidence needed to make them part of standard care. Some we need to give, others are simply nice to give.  Proton Pump Inhibitors (PPIs) in upper GI bleed emergencies According to a 2010 Cochrane review, PPIs do not affect clinically important outcomes. There was no change in mortality, re-bleeding, or the need for transfusion or surgical intervention when compared to placebo. There is also little evidence to support the method by which to administer these drugs. Bolus, infusion or both do not alter outcomes [2]. There is some data to suggest that PPIs initiated before endoscopy may reduce high-risk stigmata of bleeding at the time of scope (NNT = 15). Most endoscopists still want PPIs given to ED patients presenting with an UGIB. Take home message: * PPIs should be low priority in your resuscitation * Bolus, no infusion – save that line for other more important things * If the endoscopist wants a PPI given, give it Antibiotic prophylaxis in cirrhotic upper GI bleed emergencies Many cirrhotic UGIB patients do not die from hemorrhage but instead from bacterial infections in subsequent days. It makes sense then, that antibiotics should be part of your initial management of these patients. According to another 2010 Cochrane review, antibiotic administration was associated with reduced mortality, bacterial infections, re-bleeding events and hospitalization length of stay in cirrhotic patients. The data here is strong, with a NNT of 1 in 22 to prevent death and 1 in 4 to prevent infectious complications [6]. Take home message: * Antibiotics such as Ceftriaxone reduce mortality in cirrhotics with upper GI bleed emergencies * Make antibiotics a high priority in resuscitation Learn more about mortality benefit associated with antibiotic use in patients with UGIB in Episode 64 Highlights from Whistler's Update in EM Conference 2015 Part 2 Somatostatin Analogues: Octreotide Although a 2008 Cochrane review found no mortality benefit, there is evidence that octreotide may help prevent re-bleeding in both variceal and non-variceal UGIB patients. Octreotide reduces splanchnic blood flow and acid production, so it makes physiologic sense to give it [3]. Take home message: * Octreotide, while not life-saving,