10:00 AM, 33 yo man with a history of frequent binge-drinking presents to ED by ambulance after his flat mate found him spewing up blood in the bathroom. The two had been on a big night out, about a carton each (normal for Broome). Had a late night kebab and retired around 3 AM. The flatmate states he has been complaining of stomach aches on and off for weeks. As you walk into examine the patient he reaches for an Emi-bag and chucks up about a litre of coffee-grounds. His obs are: pulse 100, BP 110/60, RR 12, SpO2 98% RA, afebrile and has good peripheral perfusion. HIs belly is soft other than epigastric tenderness ++. No evidence of chronic liver disease or portal hypertension clinically. You put in a generous-sized IV and order a litre of saline, some antiemetic and wonder – what to do next? Here are some options:
- IV fluids, analgesia and admit for monitoring
- Call the endoscopist immediately – Urgent Scope
- Give a high dose PPI (eg esomeprazole or similar)
Here is what I would have done a few months ago – IV fluids, give a big dose of PPIs and admitted to ward to monitor and consider doing an endoscopy if he is not settling or becomes haemodynamically unwell. Any other plans – let me know on the comments.
After doing a bit of research recently into PPIs in this scenario the waters are far from clear (in my mind). Damn evidence – always makes things difficult. I think we all think of treatments such as PPIs as “good” and “harmless” but this may not be the case….
The big problem with the PPI evidence is that the studies use unusual end points – “stigmata of recent bleeding at endoscopy”, “need for further endoscopic intervention” rather than the logical ones eg. mortality, need for transfusion or laparotomy. This is a good example of disease-oriented outcomes vs. patient oriented outcomes. Most patients care little about the score the Gastro doc gave their ulcer- they just want to get better, avoid an operation and not die!
So the summary of the evidence is basically broken into 2 groups – PPIs for undifferentiated upper GI bleed and PPI for proven peptic ulcers
- that for mortality, there is a trend towards increased dying in the PPI groups, not significant, but not good either.
- For Rebleeding – almost a significant benefit, but not quite
- For need to go to theatre – similar to rebleeding, borderline for benefit.
- If you just lok at the Daneshmund trial – which is the biggest: mortality was almost statistically significantly worse for the PPI group, rebleed and theatre were basically neutral. So to compare to Vioxx – this would have almost had the FDA putting a black box label and banning PPIs in this setting, actually there was probably less evidence against Vioxx!
So here is how I think I will play it in the future. Treat the patient on clinical merits – resus as required, monitor for bleeding, check Hb etc, admit and get an endoscopy done when possible – based on clinical urgency. If I can avoid an urgent GA, wait until the dust is settled and do one under sedation. Then once you have done the scope – treat the cause – PPI, H. pylori eradication, or inject a variceal bleed etc. Do nothing except EthOH counselling if he has a Mallory-Weiss tear.
OK, that is my take on PPIs – anybody out there got a different angle? Casey
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