GI Bleeding, an Evidence Based Approach.

presented by Dr. Mark Fenig, MD

With GI bleed patients, EM docs want to a.) differentiate between Upper and Lower sources and b.) stratify the severity of the bleed. Valuable buzzwords from the patient’s history include their age, hematemesis, melena, and/or cirrhosis. Objective measures include BUN:Cr…

“Great, but what did the Nasogastric (NG) Lavage show?”

Well… NG lavage has shown to have a sensitivity of 42%(1) and… amongst incision and drainage of abscesses, fracture reduction, urethral catheterization… NG Tube placement was scored to be THE most painful procedure patients experience in the ED (2).

In one study, NG Lavage did NOT improve mortality, did NOT lessen length of stay, did NOT prevent unnecessary surgeries, and did NOT lessen need for transfusions. The only thing it DID impact was time to endoscopy; but even this was institution-specific. (3)

So what other clinical measures can we use objectively to assess which patients are high risk versus low risk GI Bleeds? In comes the Glasgow Blatchford Bleeding Score (GBBS).  There has been good external validation of GBBS; scores of 0 had no complications, no high risk lesions, and were safe for discharge. In later examinations of the scoring system, everyone with a score of 0 (15% of patients) were discharged – there were no complications and no interventions after outpatient EGD (showing low risk lesions).(4)

GBBS proved successful in ruling in bleeding too: sensitivity of 99.6% and Negative Predictive Value of 96.4%. (5)

Next time you face a patient with a GI bleed, think about the Glasgow Blatchford Bleeding Score before reaching for that painful NG tube.

mdcalc.com/glasgow-blatchford-bleeding-score-gbs

Citations

1.) Usefulness and validity of diagnostic nasogastric aspiration in patients without hematemesis. Witting et al. 2004. PubMed Id 15039700

2.) Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Singer et al. 1999. PubMed ID 10339680

3.) Impact of nasogastric lavage on outcomes in acute GI bleeding. Huang et al. 2011. PubMed ID 21737077 

4.) Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Stanley et al. 2009. PubMed ID 19091393

5.) Risk scoring systems to predict need for clinical intervention for patients withnonvariceal upper gastrointestinal tract bleeding. Chen et al. 2007. PubMed ID 17870480

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