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Clinical Case 026: Hangover Haemetemesis

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:

  1. IV fluids, analgesia and admit for monitoring
  2. Call the endoscopist immediately – Urgent Scope
  3. 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….

Well, this is a tougher question to answer than you might think! There are a few good-sized trials, but they were done in such a way that it is difficult to establish risk vs benefit in a meaningful way. The trials I am referring to include: If you want a 90 minute discussion – then go and download Smart EMs podcast on the topic, David and Ashley were not convinced!  The Cochrane Librabry has a few good reviews on PPIs in peptic disease

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

Proton-pump inhibitors in pre-endoscopy patients have not been shown to be effective for the important patient-oriented outcomes.  If you look at the meta-analysis of 3 trials by Revman you will see:

  • 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!

I think the evidence for PPIs is better in the patients whom have had an endoscopy and diagnosed a true ulcer as the cause. Also this allows rapid, accurate, in-vivo testing for H. pylori.   There is good evidence based benefit for patients with ulcers being treated with PPI and eradication therapy (Cochrane review).

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

 

Comments

  1. Casey, I too have struggled with this one. I think at best there is probably clinical equipoise and a true large scale PPI vs placebo for undifferentiated (ie. pre endoscopy) upper GI bleeding with meaningful primary outcome would be needed to put the question to bed for once and for all.

    Interestingly the GI guidelines on the subject of non-variceal UGI bleeding (Barkun AN et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010 Jan 19; 152:101.) really stress early endoscopy. They do mention using PPI in the undifferentiated patient to ‘downstage’ the lesion but explicitly mention that this should not delay endoscopic therapy. In Canada I suspect that less than 20% of patients who present with UGI bleeding are getting acute endoscopy. Most often the local specialists (general surgery or gastroenterology) want the patient admitted for PPI infusion and down staging and if the patient settles they generally leave it at that, particularly if the patient is a drinker or NSAID user.

    My own difficulty with the situation is that I think the management of these patients as above is absurd, and basically amounts just waiting to see if they crash to declare themselves. In the alcoholic patients we really have no idea which are variceal and non-variceal bleeds. In the rest I think we still generally have no idea about the aetiology of bleeding until a scope is passed. The trouble is that in my own and many other hospitals prompt endoscopy for moderate UGI bleed is just not part of the culture, rather it is an occasional occurrence that happens during daytime hours when the consultant is otherwise unoccupied. So, as hard I push for early endoscopy to define the lesion, I have to sometimes remind myself that (as Dr. Newman says) it’s not worth loosing your job over.
    Aaron

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