Twitter debate: controversies in management of upper gastrointestinal bleeding

Introduction

The latest in the series of ‘Controversies in…’ Twitter debates for Frontline Gastroenterology was led by AJS (@AdrianStanleyGI) in a discussion on the topic of acute upper gastrointestinal bleeding (UGIB). This remains a medical emergency that is frequently encountered by both general physicians and gastroenterologists, with in-hospital mortality of approximately 10%.¹ A previous Frontline Gastroenterology debate ‘controversies in the management of portal hypertension’, covered updates in variceal bleeding.² This article summarises current controversies and recent published research in the management of non-variceal UGIB.

Pre-endoscopy management

Risk scores: which score to use and does it alter clinical management?

The debate began with an evaluation of the clinical utility of risk scoring systems in the assessment of UGIB. The Glasgow Blatchford score (GBS) is now the scoring system recommended by all the major recent international guidelines for identifying patients with very low-risk UGIB (GBS 0–1) who can be considered for outpatient management.^3–5 Use of this score by clinicians in the emergency department (ED) or acute medical receiving unit allows early identification of low-risk patients who can avoid admission and have outpatient endoscopy arranged. The GBS gives junior doctors and our ED colleagues’ confidence to facilitate prompt decision making and avoid unnecessary hospital admissions.

In 2019, Shung et al used machine learning to develop a model that was able to identify patients admitted with UGIB who were at risk of requiring hospital-based intervention or death.⁶ This was found to have greater specificity and sensitivity than all the current clinical risk scoring systems. Further data on the clinical utility of this promising model are required.

Has the HALT-IT study ended the use of tranexamic acid in UGIB?

The recently published HALT-IT trial was an international multicentre, randomised, placebo-controlled study that assessed the role of tranexamic acid in 12 009 patients with gastrointestinal bleeding, of whom 89% had UGIB. The results showed that use of tranexamic acid in UGIB did not reduce mortality or rates of rebleeding, but was associated with a higher risk of venous thromboembolic events and seizures.⁷ Therefore, use of tranexamic acid in the context of UGIB is not recommended.

Why is use of proton pump inhibitor prior to endoscopy controversial?

During the debate, AJS acknowledged that guidelines with regards to proton pump inhibitor (PPI) use prior to endoscopy are inconsistent. Administration of PPI prior to endoscopy has been shown to reduce endoscopic stigmata, and therefore, also the need for endoscopy. However, there is no evidence to suggest benefit for any clinically relevant end points for example, rebleeding, need for surgery or mortality.

Restrictive versus liberal transfusions?

Large randomised control trials and a meta-analysis have demonstrated that a restrictive transfusion strategy is favourable in the context of acute UGIB.⁸ However, it must be remembered that patients with severe ongoing bleeding and patients with significant cardiovascular disease should be transfused at a higher threshold.

Optimal timing of endoscopy

Current UK and international guidelines suggest that endoscopy should be undertaken within 24 hours of admission to hospital in a patient presenting with UGIB.^{3 9} Haemodynamically, unstable patients often require aggressive resuscitation, airway support with anaesthetic input and more urgent endoscopy. However, no risk scoring system can accurately define which patients require more urgent endoscopy, that is, within a shorter time frame than 24 hours. A recent randomised control trial from Hong Kong showed no significant difference in 30-day mortality or further bleeding between endoscopy performed within 6 hours of presentation compared to between 6 and 24 hours after presentation, in higher-risk patients defined as GBS ≥12.⁹ Interestingly, a large Danish study in peptic ulcer bleeding reported a ‘U’ shaped curve when assessing survival by time of endoscopy, after adjusting for confounders. This suggests that endoscopy undertaken either too early or too late reduces survival and reinforces the importance of appropriate resuscitation and correction of comorbidities prior to endoscopy.¹⁰

Endoscopic management

What is the role of over the scope clips in UGIB?

The over-the-scope clip (OTSC), often referred to as the ‘bear claw’”, was initially developed for endoscopic closure of gastrointestinal perforations. This modality is now being used to achieve haemostasis in UGIB. The OTSC is a pioneering endoscopic adjunct that provides a strong tissue grasp and is able to take a bigger ‘bite’ than standard through the scope clips (TTSCs).¹¹ The recent STING randomised control trial found that use of OTSC was superior to standard endotherapy (haemostasis with TTSCs or thermal therapy plus injection of epinephrine) for patients with ulcer rebleeding.¹²

Hemospray: does it change outcomes?

Hemospray is an inert mineral haemostatic powder, pressurised with a carbon dioxide canister to allow delivery through a catheter to aid control of UGIB.¹³ Studies have shown it is effective at achieving immediate haemostasis, however, it has a high rate of rebleeding.¹⁴ AJS acknowledged that it is a very useful temporary holding measure in an emergency situation, to allow stabilisation of a patient prior to definitive therapy, for example, radiological embolisation or surgery. Note that in this situation, placing a clip near to the bleeding point helps subsequent radiological targeting.

Post endoscopy management

How is Helicobacter pylori status best assessed in bleeding peptic ulcers?

During the debate, it was agreed that testing for Helicobacter pylori (H. pylori) in the context of UGIB can be difficult. Biopsy during index endoscopy is helpful if positive, however, there is a high false negative rate for H. pylori in this situation. Some clinicians routinely prescribe empirical eradication therapy in the context of UGIB secondary to peptic ulcer disease. Although there is little evidence for this approach, it may sometimes be beneficial in selected patients for example, the older patient with no history of NSAID use. Regardless, it is important that patients receiving H. pylori eradication therapy after an ulcer bleed should have confirmation of eradication post treatment. This is usually done by asking the general practitioner to conduct a stool antigen test several weeks following eradication therapy.

Post scope PPI therapy: IV (intravenous) infusion, IV bolus or oral bolus?

Current evidence suggests that intermittent intravenous PPI bolus is as effective as intravenous PPI infusion in high-risk peptic ulcer disease, with similar rates of rebleeding.¹⁵ In addition, comparison of intravenous PPI bolus versus oral PPI bolus has shown no significant difference in the prevention of rebleeding, requirement for surgery, repeat endoscopy or 30-day mortality, suggesting that oral PPI can be used as an alternative to intravenous PPI post peptic ulcer UGIB.^{16 17}

How do we improve trainee exposure to endoscopy for acute UGIB?

It was recognised during the twitter debate that training in endoscopic haemostasis is crucial for trainees. Trainees have expressed varying levels of exposure to endoscopy for UGIB and have highlighted a requirement for additional training to improve skills and confidence in the endoscopic management of UGIB.¹⁸ In units that have daily dedicated slots for patients with UGIB, trainee attendance at these lists were encouraged and of great educational benefit. In addition, participation of senior trainees in a 24-hour UGIB rota allows for experience in the often challenging decision-making process out of hours. However, it was noted that this can be difficult due to general medical commitments. It was suggested that final year trainees should come off the general medical rota in order to gain experience on an UGIB rota if this can be facilitated locally. In addition, the recently developed JAG approved 1-day haemostasis course of mini-lectures, videos and hands-on model training is very helpful for trainees to improve their skills in managing patients with UGIB.

Conclusion

Acute UGIB remains a common medical emergency with a 10% mortality rate. This twitter debate highlighted controversies and recent published research in this area and summarised key aspects in the management of non-variceal UGIB.

Ethics statements

Patient consent for publication

Not required.