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….
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