NON-VARICEAL UGIB

Clinical Practice from Bench to Bedside

Is there a great divide??

MARCELIANO T. AQUINO JR. MD

FPCP, FPSG, FPSDE

OBJECTIVE

• To compare and correlate the bedside clinical practice of Filipino Gastroenterologists with available Clinical Practice Guidelines

• A questionnaire on “Knowledge, Attitudes and Practices of Filipino Gastroenterologists on NVUGIB” was distributed during the last PSG NVUGIB meeting and during the PSG-PSDE-HSP Joint Annual Convention

• Respondents composed of GI Consultants and Fellows in Training with a mean age 41.9 +/- 8.2

• A total of 81 respondents were analyzed

METHODOLOGY

Hospital Affiliations of Respondents

Academe = 73% Government = 12%

Non-training Tertiary = 10% Non-training Secondary= 5%

Clinical Practice Guidelines

• Systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific circumstances

Field and Lohr, 1990

Clinical Practice Guidelines • International Consensus

Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding

• Alan N. Barkun, MD, MSc (Clinical Epidemiology); Marc Bardou, MD, PhD; Ernst J. Kuipers, MD; Joseph Sung,

MD; Richard H. Hunt, MD; Myriam Martel, BSc; and Paul Sinclair, MSc, for the International Consensus Upper

Gastrointestinal Bleeding Conference Group* , 2009

• Asia-Pacific Working Group Consensus on Non-Variceal Upper Gastrointestinal Bleeding

• Joseph J Y Sung,1 Francis K L Chan,2 Minhu Chen,3 Jessica Y L Ching,3 K Y Ho,4 Udom Kachintorn,3

Nayoung Kim,5 James Y W Lau,3 Jayaram Menon,3 Abdul Aziz Rani,3 Nageshwar Reddy,3 Jose Sollano,6

Kentaro Sugano,7 Kelvin K F Tsoi,2 Chun Ying Wu,3 Neville Yeomans,3 Namish Vakil,8 K L Goh3, 2011

Excerpts from the Questionnaire

• Do you follow Clinical Practice Guidelines when treating patients with NVUGIB?

• Do you utilize risk stratifcation scoring system for Upper GI Bleeding in your Unit? If yes, what scoring system do you use?

• Do you use pre-endoscopy PPI? If yes, what is the dose?

• Among ASA users with high cardio-thrombotic risk who develop ulcer bleeding, when do you resume ASA?

• Do you use PPI together with ASA among high-risk patients?

• How long will you give PPI together with ASA in these high-risk patients?

• In patients who are positive for H.pylori, when do you start treatment?

• When do you perform endoscopy after presentation? within 12 hrs or within 24 hrs?

• What are the available Endoscopic Treatments in your Unit?

Do you follow Clinical Practice Guidelines when treating patients with NVUGIB?

• Among 81 respondents:

• YES = 58

• NO = 23

Do you utilize risk stratification scoring system for Upper GI Bleeding in your Unit? If yes, what scoring system do you use?

Among 81 respondents: YES = 31 NO = 50

CLINICAL PRACTICE GUIDELINES

• ICON

• Statement A2:

• Prognostic Scales are recommended for early stratification of patients into Low and High Risk Categories for rebleeding and mortality (Agree: 97%, Grade-Low, 1c)

• ASPAC

• A pre-endoscopy prognostic scale is useful to predict patients that require endoscopic intervention. (Agreement - 86.5%, Level of Evidence - moderate)

• Do you use pre-endoscopy PPI? If yes, what is the dose?

Among 81 respondents ALL use pre-endoscopy PPI

CLINICAL PRACTICE GUIDELINES

• ICON

• Statement A8:

• Pre-endoscopic PPI therapy maybe considered to down stage the endoscopic lesion and decrease the need for Endoscopic Intervention but should not delay endoscopy. (Agree: 94%, Grade-moderate, 1b)

• ASPAC

• A pre-endoscopy PPI is recommended where early endoscopy or endoscopic expertise is not available within 24 hours. (Agreement: 86.7%, Level of Evidence - low)

• A large single center RCT showed that pre-endoscopic use of PPI at a high dose can down grade the signs of hemorrhage of PUD

• Among ASA users with high cardio-thrombotic risk who develop ulcer bleeding, when do you resume ASA?

CLINICAL PRACTICE GUIDELINES

• ICON

• Statement E3:

• In patients, who receive low dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk of cardiovascular complications is thought to outweigh the risk for bleeding. (Agree: 100%, Grade-moderate, 1b)

• ASPAC

• Among ASA users, with high cardio-thrombotic risk, who develop ulcer bleeding, ASA should be resumed as soon as possible once hemostatis is established. (Agreement: 86.6%, Level of Evidence - moderate)

Do you use PPI together with ASA among high-risk patients?

Among 81 respondents: YES = 96% NO = 1%

NO RESPONSE = 4%

ACCORDING TO ICON: STATEMENT E4: In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that Clopidogrel alone has a higher risk for rebleeding than ASA combined with PPI (Agree-100%, Grade - moderate, 1b)

• Clopidogrel alone is not a safer alternative than the combination of low-dose ASA plus PPI in patients with increase risk of ulcer bleeding. (Agreement: 100%, Level of evidence - moderate)

• Among patients receiving Clopidogrel and ASA as dual treatment, prophylactic use of a PPI reduces the risk of adverse GI events (Agreement: 81.25%, Level of Evidence - moderate)

ASPAC

How long will you give PPI together with ASA in these high-risk patients?

In patients who are positive for H.pylori, when do you start treatment?

During hospitalization = 51% After Discharge = 48%

No response = 1%

ACCORDING TO ICON: STATEMENT D5: Patients with bleeding peptic ulcers should be tested for H.pylori and receive eradication therapy if it is present, with confirmation of eradication. (Agree-94%, Grade - high, 1a)

When do you perform endoscopy after presentation? within 12 hrs or 24 hrs?

• Survey (N=81) • Within 12 hours- 49%

• Within 24 hours- 51%

• National Data (N=1142) • Within 12 hours- 50%

• Within 24 hours- 50%

CLINICAL PRACTICE GUIDELINES

• ICON

• Statement B3

• Early endoscopy (within 24 hrs of presentation) is recommended for most patients with acute upper gi bleeding (Agree-100%,Grade: moderate,1b)

• ASPAC

• Endoscopic intervention within 24 hrs of onset of bleeding improves outcomes in patients at high risk (agreement: 100%,Level of Evidence: moderate)

What are the available Endoscopic Treatment in your Unit? Modality Percentage of Respondents

Injection Hemostasis 31/81 (38%)

Heater Probe 9/81 (11%)

Argon Plasma Coagulation 6/81 (7%)

Hemoclip 25/81 (30%)

Laser 3/81 (3%)

Band Ligation 19/81 (23%)

In Summary:

• Our survey shows few differences between the Clinical Practice of Filipino Gastroenterologists when compared with the Consensus Recommendations of ICON and ASPAC probably due to the following reasons:

• 1. Reliance of the Clinical Practitioners to their “tried and tested” clinical experience and expertise.

• 2. Reasons of cost of treatment and probably some recommendations are not applicable in their settings.

Recommendations: • 1. There is a need to enhance the

familiarity and adherence of the Clinical Practitioners to these Guidelines through presentation in various medical conventions and conferences.

• 2. Develop Clinical Practice Guidelines (CPG) tailored and applicable to the needs and available resources of the clinical practitioners.

THANK YOU! ☻