Risk Stratification of Acute Upper GI Bleed Patients

March 2009

Risk Stratification of Acute Upper GI Bleed Patients

Search Strategy: Reviewing Rowes’ Evidence Based Emergency Medicine (p 448) you note that guidelines exist for the management of UGI bleed, but none are written by EM. Rowe also suggests that no RCTs exist to support early vs. late EGD for UGI bleed. Searching PUBMED Clinical Queries for clinical prediction guides you obtain the articles below.

St. Patrick’s Day has come to your ED! Unfortunately, the green liquid being spouted at you is neither hops nor barley, but a toxic combination of half-digested food matter and gastric acid. Yummy! Gastroenteritis season has hit St. Louis so you glumly “march” from room-to-room to evaluate the duration of symptoms and nature of associated abdominal pain for each case.

Your seventh “vomicker” of the day is different. Mr. G is a 38 year old executive vice-president who has had no sick contacts, fever, or diarrhea. In fact, he reports vomiting blood twice today. He is hemodynamically stable with no peritoneal findings and heme-positive black stool. He has no significant past medical history, but you suspect peptic ulcer disease so you inquire about alcohol and NSAID abuse – he denies both. His labs demonstrate a normocytic anemia (hemoglobin 10) and elevated BUN/Cr ratio (40/0.7) both seeming to confirm an upper GI bleed. He has not vomited in 6-hours and notes only mild epigastric discomfort when not being palpated.

You administer an oral proton pump inhibitor and page your friendly neighborhood Gastroenterologist to recommend admission and endoscopic evaluation within 24-hours based upon current guidelines. After hearing the story, GI wants to know what his NG lavage showed. Having personally experienced an NG lavage, you advocate for no NG tube unless the patient subsequently manifests recurrent hematemesis, hematochezia, increasing pain, or hemodynamic instability. However, GI cannot/will not admit him without knowing his NG lavage result so you reluctantly insert an NG tube, administer 500 cc saline and aspirate back 400 cc of clear, non-bloody fluid. He is admitted and has EGD the next day confirming a non-bleeding gastric ulcer which is biopsied. The rest of his hospital course is uneventful.

What is the evidence to support NG aspiration of suspected UGI bleeding patients in the emergency department?


PICO Question #1

Population: Emergency Department patients with suspected acute, active non-variceal upper gastrointestinal (UGI) bleeding

Intervention: Nasogastric tube aspiration of blood

Comparison: NG tube not placed or placed but no blood aspirated

Outcome: Prognostic accuracy for UGI bleed, ICU requirements, endoscopic timing/urgency, mortality, NG tube morbidity


PICO Question #2

Population: Emergency Department patients with suspected acute, active non-variceal upper gastrointestinal (UGI) bleeding

Intervention: UGI bleed Clinical Decision Aids

Comparison: Unaided clinical gestalt

Outcome: Diagnostic accuracy for UGI bleed, prognostic accuracy for UGI bleed, ICU requirements, endoscopic timing/urgency, mortality, NG tube morbidity


Years

First years: A risk score to predict need for treatment for upper gastrointestinal haemorrhage, Lancet 2000; 356: 1318-1321. (http://pmid.us/11073021)

Second years: Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding, Am J Emerg Med 2007; 25: 774-779. (http://pmid.us/17870480)

Third years: Differentiating between patients with acute upper gastrointestinal bleeding who need early urgent upper gastrointestinal endoscopy and those who do not. A prospective study, Eur J Gastroenterol Hepatol 2003; 15: 381-387. (http://pmid.us/12655258)

Fourth years: Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis, Ann Emerg Med 2004; 43: 525-532. (http://pmid.us/15039700)


Articles

Article 1: A risk score to predict need for treatment for upper gastrointestinal haemorrhage, Lancet 2000; 356: 1318-1321
ANSWER KEY

Article 2: Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding, J Emerg Med 2007; 25:744-779
ANSWER KEY

Article 3: Differentiation between patients with acute upper gastrointestinal bleeding who need early urgent upper gastrointestinal endoscopy and those who do not: A prospective study Eur J Gastroenterology & Hepatology 2003; 15:381-387
ANSWER KEY

Article 4: Usefulness and Validity of Diagnostic Nasogastric Aspiration in Patients Without Hematemesis, Ann Emerg Med 2004; 43:525-532
ANSWER KEY


The Blatchford UGI Intervention Risk Scoring System

Admission risk marker Score component value
Blood urea (mg/dL)  
> 18 but < 22 2
≥ 22 but < 28 3
≥ 28 but < 70 4
≥ 70 6
   
Hemoglobin (g/dL) for men  
≥ 12 but < 13 1
≥ 10 but < 12 3
< 10 6
   
Hemoglobin (g/L) for women  
≥ 10 but < 12 1
< 100 6
   
Systolic blood pressure (mm Hg)  
100 – 109 1
90 – 99 2
< 90 3
   
Other markers  
Pulse ≥ 100 (per min) 1
Presentation with melena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2
The Athens UGI Active Bleeding CDR Points
Fresh Blood in NG tube 6
Hemodynamic ally unstable * 4
Hg < 8g/dL 4
WBC > 12000/µL 3

*Systolic BP < 100 and/or heart rate > 100 and/or orthostatic changes in SBP (decrease by more than 10%) or heart rate (increase of > 10%) between supine and seated position.

Low-risk is defined as score < 7 with LR+ = 7.9 _________ LR- = 0.04


Bottom Line

The Succinct Answer

Nasogastric tube placement is one of the most painful (http://pmid.us/9494307) procedures in EM with the rare potential for epitaxis (http://pmid.us/8484534), pneumothorax (http://pmid.us/1733486), tracheal-bronchial placement (http://pmid.us/3120238), and esophageal perforation (http://pmid.us/9451317). For ED patients with suspected GI bleed lacking hematemesis, on the rare occasions (2%) when NG aspiration is grossly positive (> 450 cc bright red blood), an UGI bleeding source can be safely assumed (positive-LR 11). Quantitatively, a grossly positive aspirate in this population would increase the likelihood of an UGI bleeding source from 50% to 92%. On the contrary, a negative NG lavage does not significantly affect the potential for an UGI source. Unfortunately, this diagnostic test performance is probably over-estimated since this study design left open the potential for spectrum bias (http://pmid.us/12353947), incorporation bias (http://pmid.us/18371254), and work-up bias (http://pmid.us/15354087) all of which can artificially elevate the observed diagnostic test performance (http://pmid.us/16477057).

The Blatchford UGI CDR (see below) may be useful to identify a low-risk subset of patients with suspected UGI bleed from peptic ulcer disease or varices unlikely to require further interventions. In one small validation set, absence of all these risk factors has a negative-LR = 0.028 (95% CI; 0.005 – 0.151) which would reduce a pretest probability of 45% to 2% (95% CI; 0.4% – 11%) “need to intervene”. Another single-center, retrospective comparison of the Blatchford score, the clinical Rockall score, and the complete Rockall score on ED patients with a non-variceal UGI bleed, suggested that the Blatchford is superior at identifying a subset at low-risk for recurrent bleeding (up to 30-days), interventions (transfusions, surgery), or death, reducing the likelihood of need for intervention from 69.5% to 3.5%. To evaluate the potential for active bleeding, the Athens UGI Score accurately identified a substantial subset (66%) at low-risk for active UGI bleeding which could safely permit delayed endoscopic evaluation for many patients although these findings should not be extrapolated to those with severe co-morbidities, anti-coagulation, suspected perforation, or senility since such patients were excluded. Before widespread use of these CDRs, they need to be validated in distinct locales from which they were derived and originally validated. Additionally, an impact analysis on clinician behavior, resource utilization, and patient-important outcomes ought to be assessed.

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