PHARMACOLOGICAL THERAPY (COnTd) AnTIBIOTIC THERAPY ACId SUPPRESSIOn And AGEnTS TO ARREST BLEEdInG A Antibiotic therapy should be commenced in patients with chronic liver disease who present with acute upper A High-dose intravenous proton pump inhibitor therapy (eg,
Scottish Intercollegiate Guidelines Network
gastrointestinal haemorrhage. omeprazole or pantoprazole 80 mg bolus followed by 8 mg/hour infusion for 72 hours) should be used in patients with MAnAGEMEnT OF BLEEdInG VARICES nOT COnTROLLEd BY major peptic ulcer bleeding (active bleeding or non-bleeding EndOSCOPY visible vessel) following endoscopic haemostatic therapy. C Transjugular intrahepatic portosystemic stent shunting is COnTInUATIOn OF THERAPY FOR OTHER MEdICAL COndITIOnS recommended as the treatment of choice for uncontrolled variceal haemorrhage.
Medicines known to increase the risk of upper gastrointestinal
complications should, where possible, be given in monotherapy
d Balloon tamponade should be considered as a temporary
and at the lowest effective dose to minimise the risk of upper
salvage treatment for uncontrolled variceal haemorrhage. PREVEnTIOn OF VARICEAL REBLEEdInG A Patients with healed bleeding ulcers who test negative for A Variceal band ligation combined with a beta blocker is Helicobacter pylori require concomitant proton pump recommended as secondary prevention for oesophageal inhibitor therapy at the usual daily dose if nSAIds, aspirin or variceal haemorrhage. COX-2 inhibitors are indicated. A In patients unsuitable for variceal band ligation, combination Management of acute upper and A Aspirin and nSAIds should be discontinued when patients of non-selective beta blocker and nitrate is recommended as present with peptic ulcer bleeding. lower gastrointestinal bleeding secondary prevention for oesophageal variceal haemorrhage. 105
Once ulcer healing and eradication of Helicobacter pylori are confirmed, aspirin and nSAIds should only be PORTOSYSTEMIC SHUnTS prescribed if there is a clear indication. A Transjugular intrahepatic portosystemic stent shunts should d Selective serotonin reuptake inhibitors should be used be considered to prevent oesophageal variceal rebleeding in with caution in patients who have an increased risk of patients with contraindications, intolerance to or failure of gastrointestinal bleeding, especially in patients taking endoscopic and/or pharmacological therapy. nSAIds or aspirin. A non-SSRI antidepressant may be an appropriate choice in such patients. B Transjugular intrahepatic portosystemic stent shunts should be considered to prevent gastric variceal rebleeding. d Oral anticoagulants or corticosteroids should be used with MAnAGEMEnT OF COLOnIC BLEEdInG caution in patients at risk from gastrointestinal bleeding, especially in those taking aspirin or nSAIds.
All patients with rectal bleeding should have a full history
taken, abdominal examination and should undergo digital rectal
MAnAGEMEnT OF VARICEAL UPPER GI BLEEdInG EndOSCOPIC THERAPY FOR OESOPHAGEAL VARICEAL BLEEdInG InTERVEnTIOnS A Patients with confirmed oesophageal variceal haemorrhage d In patients with massive lower gastrointestinal haemorrhage, should undergo variceal band ligation. colonoscopic haemostasis is an effective means of controlling haemorrhage from active diverticular bleeding EndOSCOPIC THERAPY FOR GASTRIC VARICEAL BLEEdInG or post-polypectomy bleeding, when appropriately skilled B Patients with confirmed gastric variceal haemorrhage should expertise is available. have endoscopic therapy, preferably with cyanoacrylate injection. VASOACTIVE dRUG THERAPY PRIOR TO EndOSCOPY
This Quick Reference Guide provides a summary of the main
A Prior to endoscopic diagnosis, terlipressin should be given to
recommendations in the SIGN guideline on Management of acute patients suspected of variceal haemorrhage. upper and lower gastrointestinal bleeding. Recommendations are graded d to indicate the strength of VASOACTIVE dRUG THERAPY AFTER EndOSCOPIC dIAGnOSIS
the supporting evidence. Good practice points are provided where
September 2008
the guideline development group wishes to highlight specific aspects of
A After endoscopic treatment of acute oesophageal variceal haemorrhage patients should receive vasoactive drug
Details of the evidence supporting these recommendations can be found
Copies of all SIGN guidelines are available treatment (terlipressin for 48 hours, octreotide, or high-dose
in the full guideline, available on the SIGN website: www.sign.ac.uk online at www.sign.ac.uk somatostatin each for three to five days).ASSESSInG GI BLEEdInG In HOSPITAL POST-EndOSCOPIC RISK ASSESSMEnT EARLY EndOSCOPY PRE-EndOSCOPIC RISK ASSESSMEnT d Patients with a full (post-endoscopic) Rockall score <3 have C Early endoscopic examination should be undertaken within a low risk of rebleeding or death and should be considered 24 hours of initial presentation, where possible. d All patients presenting with acute upper gastrointestinal for early discharge and outpatient follow up. bleeding should have an initial (pre-endoscopic) Rockall MAnAGEMEnT OF nOn-VARICEAL UPPER GI BLEEdInG score calculated. Patients with a Rockall score of 0 should be considered for non-admission or early discharge with EndOSCOPY Variable outpatient follow up. d Endoscopic therapy should only be delivered to actively d In patients with initial (pre-endoscopic) Rockall score >0 bleeding lesions, non-bleeding visible vessels and, when endoscopy is recommended for a full assessment of bleeding nitial sc technically possible, to ulcers with an adherent blood clot. A Combinations of endoscopic therapy comprising an injection ACUTE UPPER GASTROInTESTInAL BLEEdInG – InITIAL of at least 13 ml of 1:10,000 adrenaline coupled with either ASSESSMEnT PROTOCOL a thermal or mechanical treatment are recommended in Comorbidity preference to single modalities. Consider for discharge or non-admission with outpatient follow up if: B Endoscopy and endo-therapy should be repeated within 24 hours when initial endoscopic treatment was considered
no evidence of haemodynamic disturbance (systolic blood
sub-optimal (because of difficult access, poor visualisation,
pressure ≥100 mm Hg, pulse<100 beats per minute), and;
technical difficulties) or in patients in whom rebleeding is
no significant comorbidity (especially liver disease, cardiac
likely to be life threatening. Diagnosis dditional crit REBLEEdInG FOLLOWInG EndOSCOPIC THERAPY
not a current inpatient (or transfer), and;
no witnessed haematemesis or haematochezia. d non-variceal upper gastrointestinal haemorrhage not controlled by endoscopy should be treated by repeat Consider for admission and early endoscopy (and calculation of full endoscopic treatment, selective arterial embolisation or Rockall score) if: stigmata surgery. of recent or full sc
age ≥60 years (all patients who are aged >70 years should be
haemorrhage PHARMACOLOGICAL THERAPY
witnessed haematemesis or haematochezia (suspected continued
A Patients with peptic ulcer bleeding should be tested for Helicobacter pylori (with biopsy methods or urea breath test)
haemodynamic disturbance (systolic blood pressure
and a one week course of eradication therapy prescribed for *SBP - systolic blood pressure *SRH - Stigmata of recent haemorrhage
<100 mm Hg, pulse ≥100 beats per minute), or;
those who test positive. A further three weeks ulcer healing Maximum additive score prior to diagnosis = 7treatment should be given. Maximum additive score after diagnosis = 11.A In non-nSAId users, maintenance antisecretory therapy ORGAnISATIOn OF SERVICES should not be continued after successful healing of the ulcer ACUTE LOWER GASTROInTESTInAL BLEEdInG – InITIAL and Helicobacter pylori eradication. ASSESSMEnT PROTOCOL dEdICATEd GI BLEEdInG UnIT B Biopsy samples to test for presence of Helicobacter pylori Consider for discharge or non-admission with outpatient follow up if: d Patients with acute upper gastrointestinal haemorrhage should be taken at initial endoscopy prior to commencing should be admitted, assessed and managed in a dedicated proton pump inhibitor therapy. Biopsy specimens should be gastrointestinal bleeding unit. histologically assessed when the rapid urease test is negative.
no evidence of haemodynamic disturbance, and;
Successful Helicobacter pylori eradication should be
no evidence of gross rectal bleeding, and;
RESUSCITATIOn And InITIAL MAnAGEMEnT
confirmed by breath test or biopsy to minimise the risk of
an obvious anorectal source of bleeding on rectal examination/
FLUId RESUSCITATIOn
Second line treatment should be prescribed in the case of
Shocked patients should receive prompt volume Consider for admission if: replacement.
Red cell transfusion should be considered after loss of
Helicobacter pylori testing to confirm successful eradication
30% of the circulating volume.
should only be taken after proton pump inhibitor and
antibiotic therapy has been completed and discontinued.
evidence of gross rectal bleeding, or;
EARLY PHARMACOLOGICAL MAnAGEMEnT
Follow up endoscopy should be performed to confirm healing
A Proton pump inhibitors should not be used prior to diagnosis
of gastric ulcers if there is suspicion of malignancy. by endoscopy in patients presenting with acute upper gastrointestinal bleeding.
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Financial COMPANIES ENERGY UTILITIES MINING EDF set to launch bid for US group By Peggy Hollinger in Paris and Julie MacIntosh in New York Published: September 19 2008 20:13 | Last updated: September 19 2008 20:13 EDF of France is planning to go on the offensive to protect its foothold in the US with an offer for Constellation Energy , the electricity utility that agreed on Th
PHARMACOLOGICAL THERAPY (COnTd)