SGEM #16: Ho, Ho, Hold the PPI
Date: 23 December 2012
Title: Ho, Ho Hold the Proton Pump Inhibitor
Case Scenario: A jolly old man presents to the emergency department vomiting bright red blood all over his fur lined winter coat. You quickly assess his A,B,Cs. The nurse places two big IVs, you bring the advanced airway cart to the bedside and the laboratory draw appropriate blood work. The nurse then asks if you want to give 80mg pantoprazole IV bolus followed by an 8mg/hr drip.
Background on Upper GI Bleeds: Here is the usual blurb about and the problem…it’s common, it effects millions of patients every year, deadly and it’s expensive. The details:
- Upper GI bleed the most common reason for ER admit with lots of morbidity and mortality (Gilbert 1990; Longstreth 1997)
- Usually a result of peptic ulcer (Laine 1994; Silverstein 1981)
- Prevalence 170/100,00 adults each year (Blatchford 1997)
- Cost $750 million/yr in USA and utilizes lots of resources (Gralnek 1998; Gralnek 1997; Lee 1999; Longstreth 1995).
There is face validity for using PPIs during upper GI bleeds. It has seemed reasonable and has been common practice to lower the gastric acid. However, there is a cost to treatment and there should be demonstrated benefit to patient (not surgeon) oriented outcome.
Question: Does the use of PPIs prior to endoscopy in acute upper GI bleeds change patient oriented outcomes?
Reference: Sreedharan A et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Jul 7;7:CD005415. Review. PubMed PMID: 20614440.
- Populations: 2223 participants in six RCTs
- Intervention: PPI (oral or IV)
- Control: placebo, H2 blocker or no treatment prior to endoscopy
- Primary outcome was all cause mortality within 30 days after the acute bleed.
- Secondary outcomes:
- Rebleeding within 30 days
- Surgery for continued or recurrent bleeding within 30 days
- LOS in hospital
- Transfusion requirements
- Proportion of participants with high-risk stigmata at the time of endoscopy
- Proportion of participants receiving endoscopic treatment at index endoscopy
- Primary: Mortality six trials n=2223 NO DIFFERENCE
- Rebleeding five trials n=2,121 NO DIFFERENCE
- Surgery five trials n=2,165 NO DIFFERENCE
- LOS – could not be analyzed
- Trasfusion – could not be analyzed
- SRH four trials n=1,332 37.2% PPI vs. 46.5% placebo (OR 0.67; 95% CI 0.54 TO 0.84) did not stand up to sensitivity analysis and fixed effect vs. random effect model
- Active bleed at scope four trials n=1,332 8.6% PPI vs. 11.7% placebo (OR 0.68; 95% CI 0.50 to 0.93)
Authors Conclusions: “PPI treatment initiated before endoscopy for upper gastrointestinal bleeding might reduce the proportion of participants with SRH at index endoscopy and significantly reduces requirement for endoscopic therapy during index endoscopy. However, there is no evidence that PPI treatment affects clinically important outcomes, namely mortality, rebleeding or need for surgery.”
BEEM Comments: People who present to the ED with GI bleeds are usually undifferentiated. We do not know for sure the cause of the bleeding. Applying a costly treatment that does not seem to positively effect clinically important end points like mortality, need for surgery or re-bleeding does not seem wise. Proton pump inhibitors may be required but this data does not support the routine use of them before endoscopy.
BEEM Bottom Line: Routine use of proton pump inhibitors is not required in the emergency department setting for acute upper GI bleeds.
More Information: The oldest study in this systematic review was by Daneshment et al published in the BMJ in 1992. It had 1147 patients and found no difference comparing PPIs and control in mortality, rebleeding rates or requirement for surgery. They did find a significant difference between endoscopic stigmata of hemorrhage in patients treated with PPIs.
The most recent RCT of 631 patients by Lau et al
2007 in the NEJM included in the Cochrane review looked at high dose IV omeprazole vs. placebo prior to endoscopy for acute upper GI bleeds. It too found no difference in amount of blood transfused, recurrent bleeding, need for emergent surgery or death at 30 days. They did find the reduced need for endoscopic therapy 28% vs. 19% (p=<0.007).
David Newman did a great in depth review of this topic on SmartEM podcast. You can also find a good summary of this information on his website TheNNT
Case Scenario Conclusion: Jolly old St. Nick was stabilized in the emergency department. He went for endoscopy where the GI docs gave him a pre-scope dose of IV PPI anyways. He did well and was told to make some lifestyle changes.
Last weeks winner was Caroline Burge from Caboolture Hospital, Queensland, Australia. She correctly knew that Dr. Henry Jones Jr. got his nickname “Indiana” from the family dog.
Listen to the podcast to hear this weeks Keener Kontest question.
Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)
If you want to cut the KT window down to less than 1 year consider coming to SkiBEEM 2013 Feb 4-6 at SilverStar BC. Contact Teresa early in the new year to secure your spot at the BEST emergency EBM conference.
Happy holidays and we will be back next week with one final show for 2012. Stay tuned because we have a very special guest lined up for this episode.