Nutritional Management Update in Upper and Lower ......Nutritional Management Update in Upper and Lower Gastrointestinal Bleeding Nu’manAS Daud Centre of Gastroenterohepatology Wahidin

Nutritional Management Update in Upper and Lower Gastrointestinal Bleeding

Nu’man AS Daud

Centre of Gastroenterohepatology Wahidin Sudirohusudo Hospital

Division of Gastroenterohepatology, Departement of Internal Medicine

Hasanuddin University, Makassar, Indonesia

MAMCN Makassar 13 Juli 2019

• In the United States, there are approximately 350,000 hospital admissions for UGIB annually.

• The incidence of hospitalizations generally increases with age and is more common in men than in women.

• The 3 most common causes of UGIB are peptic ulcer disease (PUD), esophagogastric varices, and erosive esophagitis.

• Acute overt lower gastrointestinal bleeding (LGIB) accounts for ~20% of all cases of gastrointestinal (GI) bleeding (ACG 2016)

• Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5–10% of all patients presenting with gastrointestinal (GI) bleeding (ACG 2015)

Gambar 1. Hasil temuan endoskopi subyek.

0.4

0.8

1.5

1.9

3.1

4.6

13.8

18.8

20.7

32.9

28.7

31.8

0 5 10 15 20 25 30 35

Tukak esofagus

Tumor esofagus

Tumor duodenum

Gastropati Hipertensi Portal

Tumor lambung

Esofagitis

Varises esofagus

PRGE

Gastroduodenitis erosif

Gastroduodenitis superfisial

Tukak duodenum

Tukak lambung

%

Alvin Sangkereng, Luthfi Parewangi, Fardah Akil, H.A.M.Akil . 2008

4ETIOLOGY/SOURCE OF THE BLEEDING

UPPER GI

BLEEDING

LOWER GI

BLEEDING

esophagus –lig.Treitz of duodenum

Variceal & non variceal

lowest of lig.treitz – intestine- colon

Incidence : 40-150 episode/100.000 people/year

mortality 6-10%, 5x more common than LGIB, ♂>♀

Incidence : 20-27 episode/100.000 people/year; mortality 4-10%

85% spontaneous recover, 15% hemodynamic

disturbance (proximal terminal ileum)

COMMON CAUSE OF NON-VARICEAL

BLEEDING

› Peptic Ulcer disease

› Mallory Weiss Tears

› Dielufoy Lesion

› Vaskular malformation, and

› Watermelon stomatch (gastric antral

vascular ectasia)

› Aortoenteric fistel

› Hemobilia

› Hemosuccus pancreatikus

› Cameron lesion

› Upper Gastrointestinal Tumors

Saltzman JR. In Current diagnosis & treatment Gastroenterology, Hepatology & Endoscopy. 2009,pp324-342.

Peptic ulcers (40-70%) are the most

common cause of UGI bleeding

• Diverticulosis

• Colitis• IBD (UC>>CD)

• Ischemia

• Infection

• Vascular anomalies

• Neoplasia

• Anorectal• Hemorrhoids

• Fissure

• Dieulafoy’s lesion

• Varices• Small bowel

• Rectal

• Aortoenteric fistula

• Kaposi’s sarcoma

• UPPER GI BLEED

ACUTE LGIBDIFFERENTIAL DIAGNOSIS

DIVERTICULOSIS, DIVERTICULAR BLEEDING

HEMORRHOIDS

BLEEDING AVM

RADIATION PROCTITIS

DIFFERENTIAL DIAGNOSIS OF UGI/ LGI BLEEDING11

UGI LGI

Manifestation Hematemesis Hematokezia

Melena

Nasogastric aspirate Blood Clear

BUN/creatinin ratio Increase Normal

Peristaltic Hyperactive Normal

HYPOVOLEMIC SHOCK, SYMPTOMS, SIGN & FLUID REPLACEMENT

Blood loss

(ml)

< 750 750-1500 1500-2000 > 2000

Blood loss (%) < 15 15-30 30-40 > 40

Pulse rate < 100 > 100 > 120 > 140

Blood pressure normal normal ↓ decreased

Pulse pressure Normal or ↑ decreased ↓ decreased

Respiratory rate 14-20 20-30 30-40 > 35

Urine output (ml) > 30 20-30 30-40 > 34

Mental status Slightly anxious Mildly anxious Anxious &

confused

Confused &

lethargic

Fluid replacement crystalloid crystalloid Crystalloid &

blood

Crystalloid &

blood

Lau JY, Chung SCS. In Clinical Gastroenterology & Hepatology, 2005,p123.

BLATCHFORD SCORE SYSTEM TO DETERMINE THE INTERVENTION NEEDED

No Variable Poin No Variable Poin

1. Systolic Blood Pressure (mmHg) 4. Haemoglobin (g/dL)

for Women

100-109 1 12.0-12.9 1

90-99 2 10.0-11.9 3

< 90 3 < 10.0 6

2. Blood Urea (mg/dL) 5. Other Markers

36.5 – 44.5 2 Pulse > 100x/min 1

44.6 – 55.5 3 Melena present 1

55.6 – 139.9 4 Hepatic disease present 2

≥ 140 6 Cardiac failure present 2

3. Haemoglobin (g/dL)

for Men

12.0 – 12.9 1

10.0 – 11.9 3

< 10.0 6

Total

Score

Score 0-5: no need intervention; Score > 6: need interventionKonsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas non-Varises di Indonesia 2012;p.8-9

ROCKALL SCORE SYSTEM FOR THE SEVERITY OF THE UPPERGASTROINTESTINAL HAEMORRHAGE

1,2

No Variable Score 0 Score 1 Score 2 Score 3

1. Age

(years

old)

< 60 60 -79 > 80 -

2. Shock - Tachycardia

(Pulse>100X/min)

Blood pressure normal

Hypotension(Pulse>100X/min)

Systolic blood pressure <

100mmHg

-

3. Comorbid - - Heart Failure

Ischaemic heart disease,

Congestive heart failure,

any other major comorbidity

Renal

failure

Liver failure,

Metastatic

cancer

4. Diagnosis Mallory-Weis tear,

no lession,

no SRH

(Stigmata of

Recent

haemorrhage)

Peptic ulcer,esophagitis, or

errosiveMalignancy in the upper

GastroIntestinal-

5. SRH Major None or dark spot

only

- Blood in the upper GI,

Bleeding Active,Non

Bleeding Vissible

Vessel,Adherent Clot,Flat

Pigmented Spot

-

Total

Score

Note: Rockall score 8 related to high risk of death2

SRH=stigmata of recent haemorrhage

1. Konsensus Nasional Penatalaksanaan Perdarahan Saluran Cerna Atas non-Varises di Indonesia 2012;p.8-92. British Society of Gastroenterology Endoscopy Committee. Gut 2002;51(Suppl IV):iv1–iv6

Fig. 2 Investigation algorithm for acute GI bleed.

Confirm acute upper/lower GI bleed

Assess severity

Resuscitate

Low riskSevere/high risk Ongoing bleeding

Endoscopy on next available listUrgent endoscopy

Endoscopic therapy + Monitor closely

Surgery Monitor closely

High-risk lesion

Low-risk lesion

Endoscopic therapy

Early discharge

Period of observation before discharge

Guglielmi A, Ruzzenente A, Sandri M, et al. Risk assessment and prediction of rebleeding

in bleeding gastroduodenal ulcer. Endoscopy 2002; 34:778–786

Fig. 3 Stigmata of recent hemorrhage of peptic ulcers. a. Spurting ulcer b. Oozing

ulcer c. Ulcer with protuberant vessel d. Ulcer with pigmented spot

Type Endoscopic appearance

Ia

Ib

IIa

IIb

IIc

III

Spurting

Active oozing

Visible vessel (no active bleeding)

Adherent clot (no visible vessel)

Pigmented spot

Clean base ulcer

Nutrition and

Gastrointestinal bleeding

• Gastrointestinal bleeding (GIB) is a severe complication of abvariety of diseases like the chronic liver disease that result in the esophageal variceal bleeding, peptic ulcer on account of excessive gastric acid secretion, Helicobacter pylori infection, stress ulcer owing to shock, trauma, postoperative or severe systemic infection, and so on.

• It is one of the most common gastrointestinal emergencies, with an average mortality rate of 10% in a multicenter study conducted in all UK hospitals.

• The management of GIB requires a multi-step approach, involving endoscopic factors such as emergency endoscopy with different hemostatic devices, and clinical factors such as hospitalization, blood transfusion, and drugs

• Despite advances in the diagnosis and management of GIB, the mortality rate has not changed significantly in the last 50 years

Hearnshaw SA, Gut 2011;60:1327–35

Balaban DV, Chirurgia (Bucr) 2014;109:48–54

• The two major causes of severe UGIB are peptic ulcer and oesophageal varices due to portal hypertension.

• Management of these situations is different and should be considered separately

• The risk of rebleeding depends on the etiology and the severity of diseases.

• A fairly large number of patients are classified as low risk for rebleeding and can be safely fed immediately or the same day and discharged early.

• In case of the ulcer with low risk of rebleeding (Forrest II c and III) or in patients with gastritis, Mallory–Weiss, oesophagitis, or angiodysplasia, there is no need to delay refeeding, and they can be fed as soon as tolerated

Hebuterne X, Curr Opin Clin Nutr Metabol Care2011;14:197–201.

• Upper GIB from peptic ulcers or other nonvariceal causes generally stops spontaneously, if not, aggressive management is required

• Although its treatment has evolved rapidly in recent years, the prognosis remains poor with further bleeding or rebleeding.

• In the multidisciplinary care of patients, nutritional support has become a relevant strategy, to improve the prognosis

Posthauer ME Adv Skin Wound Care 2015;28:175–88.

Kuric J, Paraplegia 1989;27:140–5.

Smith ME, Ann Intern Med 2013;159:39–50.

A PH>6 IS NEEDED TO MAINTAIN PLATELET AGGREGATION

Time (minutes)0

80

60

40

20

0

ADP

Buffer

1001 2 3 4 5

Aggregation (%)

pH=6.0Disaggregation=77%



ADP: adenosine diphosphate Green FW et al. Gastroenterology 1978;74:38–43

• As for nutrition therapy on patients with GIB, it is customary for clinicians to institute absolute fasting for 48 to 72 hours.

• Fasting is believed to improve the ability to control intragastric pH, stabilize clots, and reduce the risk of rebleeding.

• Enteral feedings are usually withheld for 72 hours in GIB patients because the possibility of rebleeding is significantly higher in the first 72 hours, and fasting may reduce gastric secretion and gastric inflammation.

Hebuterne X, Curr Opin Clin Nutr Metabol Care2011;14:197–201.

Barkun AN, Ann Intern Med 2010;152:101–13.

• Several animal experiments (use animal models ) support, that enteral glucose may prevent the gastric mucosal injury associated with cold restraint stress, produce the increased blood flow to the terminal ileum, iIntragastricglucose increased residual volume and gastric pH, as well as decreased gastric mucosal injury.

Matheson Pj, et al. Surgery 2002;132:673–80.

Ephgrave KS, et al. J Am Coll Surg 1998;186:434–40.

Kleiman-Wexler RL, et al. Digest Dis Sci 1992;37:1860–5.

• Ozawa et al studied 49 H. pylori-positive patients with bleeding gastric ulcers.

• The results showed no significant differences in intragastric pH of patients receiving acid-reducing medications (both ranitidine and omeprazole) among fasting groups and early fed groups

Ozawa T, J Gastroenterol 2003;38:844–8

• Raff T, et al , retrospective study in burns shows that EEN may prevent the GIB (OR: 0.38; 95% CI: 0.17–0.84).

• Review and meta-analysis suggested that enteral nutrition may be as protection against stress ulceration and GIB.

Raff T, et al. Burns 1997;23:313–8.

Hurt RT, et. JPEN J Parenter Enteral Nutr 2012;36:721–31

MacLaren R, et al. The Ann Pharmacother 2001;35:1614–23

Pilkington KB, et al : a review of current literature. Anaesth Intensive Care 2012;40:253–9

Marika PE, et al : a systematic review and meta-analysis. Crit Care Med 2010;38:2222–8

• And several randomized controlled trials (RCTs) showed that early enteral nutrition (EEN) had no significant effects on treatment outcomes in patients with GIB who were treated with endoscopic hemostasis.

• And it is significant to determine when to start enteral nutrition because early feeding may reduce the cost of treatment and shorten the length of hospital stay.

Khoshbaten M, Dig Endosc 2013;25:125–9

Lo GH, J Chin Med Assoc 2015;78:642–7.

De Ledinghen V, Gastroenterol Clin Biol 1998;22:282–5.

de Ledinghen V, Digest Dis Sci 1997; 42:536–41

Hepworth CC, Gastroenterology 1995;108:113.

• Rassameehiran S, et al., a systematic review suggested the potential benefits of enteral nutrition include local nutrition to gastric tissue; stimulation of mucus and bicarbonate secretion by mucus glands and epithelial cells to maintain the mucus barrier; and increased splanchnic blood flow, which may facilitate ulcer healing.

Rassameehiran S, et al. South Med J 2015;108:419–24.

• Raff et al., a cohort of 526 severely burned patients, demonstrated that early enteral nutrition was more effective in preventing UGIB than cimetidine and antacids (3.3 vs. 8.3%, P

• It is generally argued that enteral nutrition buffers acid and by this way may decrease the risk of UGB

• Enteral nutrition may also act as a direct source of mucosal energy, induce the secretion of cytoprotective prostaglandins and mucus and improve mucosal blood flow

Mc Clave SA, et al . When to feed the patient with gastrointestinal bleeding. Nutr Clin Pract 2005; 20:544–550.

Ephgrave KS, et al . Enteral nutrients prevent stress ulceration and increase intragastric volume. Crit Care Med 1990; 18:621–624.

• Marik et al. ; a systematic review and a meta-analysis of the literature to determine the benefit and risks of SUP and the moderating effect of enteral nutrition.

• Overall, SUP with a histamine-2 receptor blocker reduced the risk of gastrointestinal bleeding [odds ratio 0.47; 95% confidence interval (CI) 0.29–0.76; P

EARLY ENTERAL NUTRITION (EEN) VERSUS DELAYED ENTERAL (DEE)IN PATIENTS WITH GI BLEEDING

Zhang H, et al 2019, Systematic Review and Meta-Analysis; Medicine (2019) 98:11

DEN = delayed enteral nutritionEEN = early enteral nutrition,GIB = gastrointestinal bleeding

313 patients



Rebleeding forest plot.


• The EEN was no associated with rebleeding compared with DEN.

• There was a tendency for a decreased rebleeding rate in the EEN group, but the trend was not significant (RR=0.75, 95% CI: 0.34–1.64).

Mortality forest plot



The incidence of mortality of EEN and DEN, there was no significant difference was found between

the EEN and DEN groups (RR=0.74, 95% CI: 0.23–2.39, I2=0)

Hospitalized days forest plot



The pooled analysis showed that EEN was related to reduced hospitalized days (MD= -1.69,

95% CI: - 2.15 to -1.23; I2=27%).

• In conclusion, our results indicated that EEN within 24 hours does not relate to higher rebleeding and mortality compared with DEN for patients with GIB, but decrease hospitalized days.

• EEN should be recommended as the preferred nutrition routine in the patients who are at low risk for rebleeding.

• However, multicenter, randomized clinical trials are warranted to verify these findings.



Mcclave and Chang FEEDING THE GI BLEEDER, October 2005; 545-550 ; Vol. 20, No. 5

Conclusion

Systematic fasting of patients with UGIB should be avoided.

Nutrition strategy should be based on endoscopic findings

Enteral nutrition is probably the best way to prevent bleeding in ICU patients, and nonhaemorrhagic

oesophagus varices are not a contraindication to tube feeding.

SUMMARY

• The management of GIB requires a multi-step approach, involving endoscopic factors such as emergency endoscopy with different hemostatic devices, and clinical factors such as hospitalization, blood transfusion, drugs and nutrition

• The risk of rebleeding depends on the etiology and the severity of diseases, and nutritional support has become a relevant strategy, to improve the prognosis

• Potential benefits early enteral nutrition (EEN); include local nutrition to gastric tissue; stimulation of mucus and bicarbonate secretion by mucus glands and epithelial cells to maintain the mucus barrier; increased splanchnic blood flow, which may facilitate ulcer healing

• Enteral nutrition may also act as a direct source of mucosal energy, induce the secretion of cytoprotective prostaglandins and mucus and improve mucosal blood flow

• May reduce the cost of treatment and shorten the length of hospital stay, buffers acid and by this way may decrease the risk of UGB

THE END

REFF

• Marik PE, Vasu T, Hirani A, Pachinburavan M. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit Care Med 2010; 38:2222–2228. This meta-analysis suggests that enteral nutrition is the best stress ulcer prophylaxis and that association with proton-pump inhibitors or H2 blockers might be harmful

• Van den Berg B, van Blankenstein M. Prevention of stress-induced upper gastrointestinal bleeding by cimetidine in patients on assisted ventilation. Digestion 1985; 31:1–8.

• Apte NM, Karnad DR, Medhekar TP, et al. Gastric colonization and pneumonia in intubated critically ill patients receiving stress ulcer prophylaxis: a randomized, controlled trial. Crit Care Med 1992; 20:590–593.

• Ben-Menachem T, Fogel R, Patel RV, et al. Prophylaxis for stress-related gastric hemorrhage in the medical intensive care unit: a randomized, controlled, single-blind study. Ann Intern Med 1994; 121:568–575.

• Cook DJ, Guyatt G, Marshall JC, et al. A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding patients requiring mechanical ventilation. N Engl J Med 1998; 338:791–797.

REFF

• Cook DJ, Heyland DK, Griffith L, et al. Risk factors for clinically important upper gastrointestinal bleeding in patients requiring mechanical ventilation. CritCare Med 1999; 27:2812–2817.

• Mc Clave SA, et al . When to feed the patient with gastrointestinal bleeding. Nutr Clin Pract 2005; 20:544–550.

• Ephgrave KS, et al . Enteral nutrients prevent stress ulceration and increase intragastric volume. Crit Care Med 1990; 18:621–624.

• Raff T, Germann G, Hartmann B. The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patient. Burns 1997; 23:313–318.

• Choctaw WT, Fujita C, Zawacki BE. Prevention of upper gastrointestinal bleeding in burn patients: a role for ‘elemental’ diet. Arch Surg 1980; 115:1073–1076.

• Hearnshaw SA, Logan RF, Lowe D, et al. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut 2011;60:1327–35.

• Balaban DV, Strambu V, Florea BG, et al. Predictors for in-hospital mortality and need for clinical intervention in upper GI bleeding: a 5-year observational study. Chirurgia(Bucr) 2014;109:48–54.

• Posthauer ME, Banks M, Dorner B, et al. The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, European pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper. Adv Skin Wound Care 2015;28:175–88.

• Kuric J, Lucas CE, Ledgerwood AM, et al. Nutritional support: a prophylaxis against stress bleeding after spinal cord injury. Paraplegia 1989;27:140–5.

• Smith ME, Totten A, Hickam DH, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med 2013;159:39–50.

• Hebuterne X, Vanbiervliet G. Feeding the patients with upper gastrointestinal bleeding. Curr Opin Clin Nutr Metabol Care 2011;14:197–201.

• Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on themanagement of patientswith nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152:101–13.

• Ozawa T, Yoshikawa N, Tomita T, et al. The influence of feeding on gastric acid suppression in Helicobacter pylori-positive patients treated with a proton pump inhibitor or an H2-receptor antagonist after bleeding from a gastric ulcer. J Gastroenterol 2003;38:844–8.

• KhoshbatenM, Ghaffarifar S, Jabbar Imani A, et al. Effects of early oral feeding on relapse and symptoms of upper gastrointestinal bleeding in peptic ulcer disease. Dig Endosc 2013;25:125–9.

• Lo GH, Lin CW, Hsu YC. A controlled trial of early versus delayed feeding following ligation in the control of acute esophageal variceal bleeding. J Chin Med Assoc 2015;78:642–7.

• De Ledinghen V, Beau P, Mannant PR, et al. When should patients with bleeding peptic ulcer resume oral intake? A randomized controlled study. Gastroenterol Clin Biol 1998;22:282–5.

• de Ledinghen V, Beau P, Mannant PR, et al. Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study. Digest Dis Sci 1997; 42:536–41.

• Hepworth CC, Newton M, Barton S, et al. Randomized controlled trial of early feeding in patients with bleeding peptic ulcer and a visible vessel. Gastroenterology 1995;108:113.

• Raff T, Germann G, Hartmann B. The value of early enteral nutrition in the prophylaxis of stress ulceration in the severely burned patient. Burns 1997;23:313–8

• Hurt RT, Frazier TH, McClave SA, et al. Stress prophylaxis in intensive care unit patients and the role of enteral nutrition. JPEN J Parenter Enteral Nutr 2012;36:721–31.

• MacLaren R, Jarvis CL, Fish DN. Use of enteral nutrition for stress ulcer prophylaxis. The Ann Pharmacother 2001;35:1614–23.

• Pilkington KB, Wagstaff MJ, Greenwood JE. Prevention of gastrointestinal bleeding due to stress ulceration: a review of current literature. Anaesth Intensive Care 2012;40:253–9.

• Marik PE, Vasu T, Hirani A, et al. Stress ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit Care Med 2010;38:2222–8.

• Rassameehiran S, Nugent K, Rakvit A. When should a patient with a nonvariceal upper gastrointestinal bleed be fed? South Med J 2015;108:419–24.

• Matheson PJ, Lusco V, Wilson MA, et al. Omega-3 fatty acids in immune-enhancing enteral diets selectively increase blood flow to the ileum by a bile acid dependent mechanism. Surgery 2002;132:673–80.

• Ephgrave KS, Brasel KJ, Cullen JJ, et al. Gastric mucosal protection from enteral nutrients: role of motility. J Am Coll Surg 1998;186:434–40.

• Kleiman-Wexler RL, Ephgrave KS, Broadhurst KA. Effects of intragastric and intravenous glucose on restraint model of stress ulceration. Digest Dis Sci 1992;37:1860–5.

• Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5–10% of all patients presenting with gastrointestinal (GI) bleeding (ACG 2015)

• Lower gastrointestinal bleeding (LGIB) has an estimated incidence of 33–87/100 000 and accounts for 3% of emergency surgical referrals (BSG 2019)

• Acute overt lower gastrointestinal bleeding (LGIB) accounts for ~20% of all cases of gastrointestinal (GI) bleeding (ACG 2016)

Documents

Nutritional Management Update in Upper and Lower ......Nutritional Management Update in Upper and Lower Gastrointestinal Bleeding Nu’manAS Daud Centre of Gastroenterohepatology Wahidin