Gastrointestinal – Journal Summaries
22/7/10
VARICEAL BLEEDING
Hayes, PC., et al (1990) “Meta-analysis of value of propanolol in prevention of variceal
haemorrhage” Lancet 336:153-156
-
meta-analysis of controlled trials
looking at prevention of primary and secondary variceal bleeding
propanolol works for primary prevention
endoscopic band ligation for acute bleeding
ULCER PREVENTION AND TREATMENT
Lay, JY., et al (2000) “Effect of intravenous omeprazole on recurrent bleeding after
endoscopic treatment of bleeding peptic ulcers” N Eng J Med 343:310-316
- double blind RCT
- n = 240
- actively bleeding ulcers or non-bleeding visible vessels after treatment with adrenaline +
thermocoagulation
- omeprazole 80mg bolus -> 8mg/hr for 72 hours VS placebo
- all patients received 20mg PO omeprazole for 8/52
- significant reduction in rate of bleeding within 30 days (most of which happened in first 3
days) in treatment group
- no difference in mortality
- no difference in number of patient requiring surgery
Messori, A., et al (2000) “Bleeding and pneumonia in intensive care patients given ranitidine
and sucralfate for prevention of stress ulcer: meta-analysis of randomised controlled trials”
BMJ 321:1103-1106
- incidence of pneumonia and bleeding -> thought to be potential adverse effect of gastric
acid suppression c/o bacterial overgrowth
- small numbers in studies
- no benefit from ranitidine vs placebo
- no benefit from sucralfate vs placebo
- increase risk of nosocomial pneumonia in ranitidine vs sucralfate
-> muscosal ischaemia more important than acidity in stress ulcer formation
-> despite this evidence use of PPI is widespread in critical care
Parsonnet, J. et al (2005) “Clinician-discoverers – Marshal, Warren and H. pylori” N Engl J
Med, 353:2421-2423
- acknowledgement of these guys discovery
- H.pylori causes: chronic superficial gastritis, chronic active gastritis, peptic ulcer disease and
gastric adenocarcinoma
Jeremy Fernando (2011)
Cook, D et al (1998) “A comparison of sucralfate and ranitidine for the prevention of upper
gastrointestinal bleeding in patients requiring mechanical ventilation” Canadian Critical Care
Trials Group, NEJM, 338:791-7
- MRCT
- placebo vs ranitidine vs sucralfate
-> GIH: placebo ( ), ranitidine (1.7%), sucralfate (3.8%) – P < 0.05
-> pneumonia incidence: ranitidine (19.2%), sucralfate (16.2%) – P > 0.05
-> no change in LOS or mortality
Mariki, P. E. et al (2010) “Stress ulcer prophylaxis in the new millennium: A systematic review
and meta-analysis” Critical Care Medicine: Volume 38 - Issue 11 - pp 2222-2228
Background
- stress ulceration uncommon (1%)
- prophylaxis may be unwarranted if feeding can be established early
- prophylaxis may increase risk of hospital-acquired pneumonia and Clostrodium difficile
infection
- meta-analysis of RCT’s
- histamine-2 receptor blockers vs placebo
- 17 studies (1836 patients)
- primary end point: clinically significant GIH
- secondary end points: incidence of HAP and hospital mortality.
- sub group analysis performed by grouping studies by enteral nutrition or no enteral nutrition
-> significant decrease in risk of gastrointestinal bleeding (OR 0.47, p < 0.02)
-> BUT only noted in a subgroup of patients who did not receive enteral nutrition (OR 1.26,
CI 0.43-3.7)
-> if patients fed, prophylaxis did not alter the risk of GI bleeding
-> no increase in risk of HAP overall
-> BUT, those who were fed had an increased risk of HAP (p 0.02, or 2.81)
-> stress ulcer prophylaxis did not change mortality
-> the subgroup who received stress ulcer prophylaxis AND enteral feeding had a elevated
HAP rate (? both increasing gastric pH and thus allowing gastric multiplication of bacteria and
subsequent aspiration)
Internal Validity
- clinically significant GIH was defined by each individual study
- if there wasn’t a definition of clinically significant bleeding then endoscopic bleeding was
used.
- used H2 antagonists: cimetidine, ranitidine, famotidine
- varying doses
- some studies ran infusions
- only 3 studies looked at enteral nutrition
External Applicability
- we use omeprazole
- those who were fed may have been sicker than those that weren’t which may explain
increase in HAP and death (confounding)
Jeremy Fernando (2011)
MY APPROACH
-
feed early unless contraindicated
don’t use prophylaxis if feeding established
if unable to establish enteral feed, risk assess for GIH: if high risk -> use prophylaxis
if develops stress ulcers treat
vigilance for the development of hospital acquired pneumonia
may need to take ulcer prophylaxis of FASTHUG sticker!
Jeremy Fernando (2011)