Non Variceal Upper GI Bleed

60 Years old malay gentleman with history of prolong usage of Tab. Diclofenac acid 50 mg PRN due to chronic osteoarthritis presented with history of blackish discoloration of stool X 5/7 and vomiting out blood on the day of admission.

1) Comment on the appropriateness of the medication given to the patient

2) List the causes of non variceal upper GI Bleed

3) Outline the management for this gentleman.

1) NSAIDs and Upper GI Bleed

NSAIDs is a known causative agent for non variceal upper GI Bleed especially if used in old age patient. Non selective inhibitors of cyclooxygenase enzyme inhibit both COX 1 and COX 2 isoenzymes resulting in inhibition of both prostaglandin and thrombaxane.

In contrast to that, selective COX 2 inhibitor like celecoxib (celebrex) is specific to inhibit the inflammation and reduce the risk of peptic ulceration. However, usage in older population should be use with caution as it may worsen the pre existing myocardial infarction, increase risk of cardiac arrythmia, stroke and vascular complication in diabetic patient.

Study shows that newer COX 2 inhibitor drug like valdecoxib do not increase the risk of cardiac arrythmia.

Another alternative for osteoarthritis is by giving opiod based medication like tramadol. Daily usage of tramadol 200 or 300 mg tramadol in elderly patient, >65 years old with osteorthritis is efficacious and tolerable.

2) Causes of Non Variceal Upper GI Bleed

a) Bleeding peptic ulcer (most common)

- common with aspirin/ NSAIDs ingestion

- Helicobacter pylori is less prevalent

b) Acute erosive gastritis

- association with NSAIDs, Steroid, alcohol

- stress ulcer secondary to shock, hepatic failure, head injury

c) Esophagitis

d) Mallory Weiss tear

e) Stomach carcinoma or lymphoma

f) others

3) Management of Upper GI Bleed

a) Triage the patient based on severity of the bleeding. For a precaution, moderate to severe UGIB should be triage to the red zone with the presence of resuscitation trolley and monitoring.

b) Check the patency of the airway and adequacy of breathing and circulation

c) Set 2 large bore IV canulla

d) Oxygen 3L/min via nasal prong

e) intubate the patient if patient is drowsy,comatose as risk for aspiration is high if patient continue to vomit.

f) Draw blood for investigation (FBC, RFT/ LFT, GXM 2 unit, GSH, PT/aPTT)

g) Fluid resuscitation with Normal Saline, Ringer's lactate or colloid.

h) Transfuse if

- Systolic BP < 110mmHg

- Postural hypotension

- Pulse >110/min

- Hemoglobin < 8g/dl

- Angina or cardiovascular disease with hemoglobin < 10 g/dl

i) Continuos bladder drainage and central venous pressure monitoring. Strict input/ output chart.

j) Keep patient nil by mouth

k) Insert nasogastric tube to monitor the bleeding as well as to decompress the stomach

l) Emergency endoscopy for bleeding evaluation and treatment.

- Staging with Forrest classification

- thermal, injection, mechanical or combination technique to stop the bleeding

m) Medical Treatment

- IV Omeprazole 80mg stat followed by an infusion of 8mg hourly for 72 hours

** PPI increase the PH of stomach therefore promote platelet aggregation and reduce fibronolyhtic activity.

** Some physician may give IV Ranitidine 150 mg stat. However, evidence shows that the use of H2 antagonist in UGIB is not recommended.

n) Discontinue the irritative medication

o) Dispose the patient base on severity. Stable patient may be dispose to medical unit.

Reference

1) Malaysia Clinical Practice Guideline for Management of Non Variceal Upper Gastrointestinal Bleeding, April 2003

2) Sarapa N, Britto MR, Cotton B, et al, "Valdecoxib, a COX-2-specific inhibitor, does not affect cardiac repolarization, J Clin Pharmacol. 2003 Sep;43(9):974-82.

3) Burch F, Fishman R, Messina N, Corser B, et al, "A Comparison of the Analgesic Efficacy of Tramadol Contramid® OAD versus Placebo in Patients with Pain due to Osteoarthritis", Journal of pain and symptom management. 2007; 34(3): 328-339.

4) Gérald Mongin, Vladimir Yakusevich, Adorjan Kope et al, "Efficacy and Safety of Once-Daily Tramadol", Clin Drug Invest. 2004;24(9) © 2004 Adis Data Information BV .