Hepatic Failure/GI/Endocrine Emergencies
| (2) | Endoscopic therapy for an adherent clot resistant to vigorous irrigation is controversial. |
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Patients with clinical features associated with a higher risk of rebleeding (e.g., older
age) may benefit from endoscopic therapy.
| (3) | Endoscopic therapy should not be used for ulcers with a flat pigmented spot or clean |
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base.
| (4) | Endoscopic therapy includes hemostatic clips, epinephrine injection, and thermal |
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therapy. Often, these therapies are combined. Epinephrine injection should not be
used alone but should be combined with a second modality.
| (b) | Other findings (e.g., erosions or Mallory-Weiss tear) are typically unamenable to |
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endoscopic therapy.
iii.
Variceal UGIB
| (a) | The primary endoscopic therapy for esophageal varices is endoscopic band ligation, |
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which is preferred to sclerotherapy.
| (b) | Sclerotherapy is recommended in patients for whom endoscopic band ligation is unfeasible. |
|---|---|
| (c) | Gastric varices are often unamenable to endoscopic band ligation, and rescue therapies |
may be necessary (discussed later in the chapter).
Pharmacologic management
Non-variceal UGIB
Acid-suppressive therapy is the mainstay of pharmacologic therapy for acute non-variceal
UGIB.
ii.
Gastric acid inhibits platelet aggregation, impairs clot formation, and promotes fibrinolysis.
In in vitro studies, inhibiting gastric acid and raising the intragastric pH to 6 or higher may
promote clot formation and decrease the risk of rebleeding. However, clinically, a pH of 4–5
should likely be sufficient.
iii.
Histamine-2 receptor antagonists are ineffective at achieving a pH greater than 6 and have
shown inconsistent benefit; therefore, these agents are not recommended for patients with
acute ulcer-related UGIB.
iv.
Adding octreotide to PPI therapy does not appear to reduce hospital or ICU length of stay,
rebleeding, or mortality in patients with nonvariceal UGIB and is not routinely recommended.
High-dose PPIs should be used as an adjunct to endoscopic therapy.
| (a) | The most recent American College of Gastroenterology guidelines do not recommend for |
|---|
or against the use of pre-endoscopic PPIs in patients with UGIB. This is a change from
prior versions, which stated that pre-endoscopic PPIs could be considered to decrease the
need for endoscopic therapy.
| (b) | High-dose PPI is defined as 80 mg/day or more for 3 days or more. This can be administered |
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as a continuous infusion or as intermittent boluses.
| (c) | High-risk patients with UGIB because of ulcers who underwent endoscopic therapy |
|---|
should receive high-dose PPI treatment for 3 days, followed by twice-daily therapy for 2
weeks after the index endoscopy.
Variceal UGIB
Octreotide, a somatostatin analog, should be initiated promptly when variceal UGIB is
suspected and continued for 2–5 days after the diagnosis is confirmed.
| (a) | Octreotide causes selective splanchnic vasoconstriction through inhibition of the release of |
|---|
vasodilatory peptides (mainly glucagon). Octreotide may also have a local vasoconstrictive
effect. Splanchnic vasoconstriction decreases portal inflow, which indirectly reduces
variceal blood flow and hemorrhage volume.
| (b) | Typically given as a 50-mcg bolus, followed by a 50-mcg/hour continuous intravenous |
|---|
infusion